key: cord-0814182-de4lbc24
authors: Rosenberg, Hananel; Ophir, Yaakov; Billig, Miriam
title: OMG, R U OK? [Image: see text]: Using Social Media to Form Therapeutic Relationships with Youth at Risk
date: 2020-08-17
journal: Child Youth Serv Rev
DOI: 10.1016/j.childyouth.2020.105365
sha: 4e7609f8f963c6c5a17526ffa7fe88cdb9124ac2
doc_id: 814182
cord_uid: de4lbc24

The rising of social media has opened new opportunities for forming therapeutic relationships with youth at risk who have little faith in institutionalized interventions. The goal of this study is to examine whether and how youth care workers utilize social media communications for reaching out to detached adolescents and providing them emotional support. Qualitative in-depth interviews (N=17) were conducted with counselors, social workers, and clinical psychologists who work with youth at risk. A thematic analysis of the interviews revealed three principal psychosocial usages of social media: (1) Reaching out and maintaining reciprocal and meaningful therapeutic relationships with youth at risk over time; (2) Identifying risks and emotional distress; and (3) “stepping in” and providing psychosocial assistance, when needed. These beneficial practices are made possible through the high accessibility and the sense of secured mediation that characterize social media communication and that complement the psychosocial needs of youth at risk. Alongside these advantages, the analysis yielded several significant challenges in social media therapeutic relationships, including privacy dilemmas and blurring of authority and boundaries. Given that social media communication is a relatively new phenomenon, the applied psychosocial practices are shaped through a process of trial and error, intuitive decisions, and peer learning. Although the main conclusion from this study supports the notion that the advantages of social media therapeutic relationships with youth at risk outweigh their problematic aspects, future research is recommended to establish clear guidelines for youth caregivers who wish to integrate the new media in their daily psychosocial work.

Youth who are, or may be, at risk of physical, mental, or emotional harm suffer from a wide range of difficulties that endanger them and threaten their ability to function, currently or in the future.

Unfortunately, adult caregivers are not always aware of their children, patients, or students' emotional struggles and the at-risk youth often drift away from conventional supporting environments, such schools and youth movements. Instead, they wander around unsupervised, seeking adventures and belongingness in alternative, and in some cases dangerous, settings (Resnick & Burt, 1996) .

One of the principal challenges in supporting these detached youth is the very formation and maintenance of solid and trustful relationships. When confronting hardships, many adolescents at risk prefer not to turn to their parents or teachers for psychosocial support (Grinstein-Weiss, Fishman & Eisikovits, 2005) . However, in some cases they are willing to accept help from informal counselors and social workers (Kaim & Romi, 2015) . This informal help is crucial for their mental health because one of the key factors that can help at-risk youth successfully navigate their complex challenges is a rich and supportive environment and a strong relationship with a caring adult figure (Gilat, Ezer, & Sagi, 2011) .

Remarkably, new opportunities for reaching out and supporting youth at risk have aroused with the outbreak of online social media. Youth all over the world spend large amount of time online every day and perceive the various social networks technologies (e.g., Instagram, WhatsApp) as a most convenient channel of communication. In many cases they would even prefer text-based communication online over other forms of communication, including face-to-face (Joshi, Stubbe, Li, & Hilty, 2019) . Recognizing these trends, some educators and school counselors have started to establish online connections with teenagers under their care in an attempt to offer them guidance and emotional support (Asterhan & Rosenberg, 2015) . However, in spite of these spontaneous initiatives, little is known about the extent and the ways in which caregivers utilize online communication for establishing positive and trustful relationships with youth at risk.

The goal of the current study is to examine whether and how social media can be utilized for reaching out and providing emotional support to at-risk youth (adolescents and emerging adults).

We hypothesized that youth caregivers would leverage the new media to overcome one of the main obstacles that characterize youth at risk. In many cases, these distressed adolescents disengage from institutionalized support systems, such as family, school, and youth movements and wonder around, searching for novel and distant spaces, away from their community. This allows them to achieve a sense of freedom and control but also places an obstacle in front of the adults who wish to contact and support them (Kaim & Romi, 2015) .

In this study, we focus on youth caregivers who work with a unique population of youth at risk from small isolated settlements in the east border of Israel, yet, the conclusions are relevant for similar rural areas around the world. Like other youth at risk, they too, are at risk of substance use, problematic sexual behaviors, and school dropouts. However, they are also at risk for a unique identity crisis. In many cases, these youth rebel against their parents' religion and values. The ideological tension between the conservative small communities and the excitements and temptations that are evident in the 'big city' or in the mass media contributes to this rebellion and distance them from their families and community (Shemesh, 2000) . These youth are also dispersed in a relatively large geographical space, with limited transportation options. Youth workers in this geographical location may therefore tend to rely on non-formal communication methods, even more than in other urban communities. The current research aims to learn from the accumulating experience of these workers (psychologist, social workers, and counsellors) and provide a window to the benefits and limitations of social media therapeutic relationships between caregivers and youth at risk.

The enormous popularity of social media among children and adolescents led many educators to start utilizing the various social networks for online communication with their students. This emerging trend raised multiple ethical and educational challenges, including concerns that the adult educational authority will keep deteriorating and that the privacy of both educators and students will be compromised. However, despite these concerns, some policymakers and educators have integrated the online communication in their daily educational practices (Greenhow, Robelia, & Hughes, 2009; Hershkovitz, Abu Elhija, & Zedan, 2019; Asterhan & Rosenberg, 2015; . Teachers use online communication for improving group and individual studying, extending learning time beyond school settings, and managing the logistics of their class activities. Some teachers even extend their educational role to include the new media environment and took upon themselves to supervise and monitor online forums, identify signs of personal distress, and assist students in need. Finally, some educators leverage the informality that characterizes the various social networks, to get acquainted with the social and cultural aspects of their students life and deepen their relationships with them (Forkosh-Baruch, Hershkovitz, & Ang, 2015; Hershkovitz & Forkosh-Baruch, 2013; .

Online communication has been also leveraged by educators for delivering emotional support to their students. During the 2014 Israel-Gaza war for example, the majority of the teachers in the Israeli cities that were exposed to war-related events provided support and empowered their students using non-formal communication methods, such as Facebook and WhatsApp. Notably, most students valued their teachers outreach effort and reported that it contributed to their general sense of resilience (Ophir, Rosenberg, Asterhan, & Schwarz, 2016) . Aside from benefiting from the concrete psychological aid online, it seems that the very existence of a continuous relationship online with a caring adult, had a significant contribution to the adolescent' sense of control and belonging (Rosenberg, Ophir, & Asterhan, 2018) . These 'semi-therapeutic' communications join teachers efforts to detect signs of distress from their students' online activities and to provide them emotional support at normal times (i.e., not at wartime) (Hershkovitz & Forkosh-Baruch, 2013; Forkosh-Baruch, Hershkovitz, & Ang, 2015; Asterhan & Rosenberg, 2015) .

The therapeutic value of the very existence of online relationships has been examined in other, non-educational settings. For example, users suffering from depression who joined Facebook support groups showed a significant improvement, especially when one of the "Facebook friends" in the group was a psychiatrist (Mota Pereira, 2014). Given that only very few patients in this particular study actually contacted the psychiatrist via Facebook, it seems that simply knowing they had access to professional medical assistance contributed to their subjective well-being. This positive psychological experience can be explained by the authentic discourse that characterizes the instant and synchronous-textual communication in the new media (Lapidot-Lefler & Barak, 2012) . The informal sharing of personal content and the removal of barriers such as embarrassment, especially among adolescents (Bardi & Brady, 2010) provide users with the opportunity to achieve emotional relief, which in some cases may even surpass the emotional benefit that is "allowed" in the traditional face-to-face communication (Dolev-Cohen & Barak, 2013) .

In fact, a dominant theme that emerged from a recent narrative analysis of anonymous online stories on suicide and self-harm behaviors, was 'overcoming silence and isolation'.

According to the authors, the anonymous communication online enables young people who feel invisible and experience emotional distress to resist oppressive social norms and turn their emotional struggles into testimonies and stories worth telling (Yeo, 2020) . Correspondingly, qualitative interviews with 15 young recipients (< 24 year-old) of online outreach services reported that social medica and WhatsApp communication enables them to speak freely about their emotional problems, even more than face-to-face interactions (Chan & Ngai, 2019).

The unique advantage of online communication in creating a comfortable platform for emotional disclosure is well documented in the research on psychological counseling online (via email or video-chats). In fact, online counselling has gained much experience since the late 1990s (Mallen, Vogel, Rochlen, & Day, 2005) and today many people use online platforms to overcome emotional distress and to improve their overall well-being (Andersson et al., 2014; Mota-Pereira, 2014; Richards & Richardson, 2012) . Indeed the specific research on social media counselling is scarce and one cannot assume that this new medium would share the same characteristics of the somewhat more formal communication through email or video-chat. However, as described above, social media communication may especially relevant to youth. In the following section we expand on the potential benefits and limitations of social media in the context of therapeutic relationships.

On the one hand, using social media to improve the well-being of youth at risk seems most relevant. In contrast to adults, adolescents may be less cooperative with conventional therapeutic efforts and prefer tactics of avoidance and escape (Kaim & Romi, 2015) . In fact, a primary difficulty in working with at-risk youth is to bring them to the health service gate and therapists struggle in maintaining ongoing therapeutic relationships. Adolescents are not always aware of the available mental health services and even when they are, they fear the negative stigma associated with seeking help, which will damage their "tough" image in the eyes of their peers (Ben Hur & Giorno, 2010) . In the digital realm, however, adolescents can receive discreet psychological support (Barak & Dolev-Cohen, 2006; Dolev-Cohen, & Barak, 2013; Valkenburg & Peter, 2009 ), without fearing from real or imagined social sanctions (Friedman & Billig, 2018) . The online communication is usually voluntary (i.e., it is not being mandated by the adult) and the adolescent is prone to feel more comfortable and less shameful (Ben Hur & Giorno, 2010) .

On the other hand, despite the above-mentioned benefits, therapeutic interventions via social media have limitations and challenges, precisely due to the characteristics of online communication. First, the informality and the blurred boundaries that characterizes social media communication may undermine the caregiver authority and create a false presentation as if the relationships between the adolescent and the caregiver are symmetrical (Asterhan & Rosenberg, 2015) . Therefore, computer-mediated relationship requires clear behavioral procedures to avoid deviation from an appropriate therapist-patient relationship (Barak, Klein, & Proudfoot, 2009 ).

Second, the physical distance between the parties makes it difficult to establish a long-term commitment to treatment, or to provide immediate assistance in situations requiring physical access to the patient, such as cases of potential suicide (Amichai-Hamburger et al., 2014) . Finally, the very notion that youth at risk will be open and responsive to social media based outreach efforts is yet to be studied. Freshmen students for example, who published Facebook posts that included explicit references to emotional distress, reported that they prefer being approached directly, in a face-to-face manner (Whitehill et al., 2013) . Indeed, the majority of these students were willing to accept help from their professors or teachers' assistants, but they also expressed their concerns that strangers would monitor their Facebook activity, even if this is done with good intention (Whitehill et al., 2013) .

The complex picture that arises from the literature emphasizes the need for effective and safe training programs for mental health workers (Barak, Klein, & Proudfoot, 2009 ). However, despite this growing need and despite the rising number of studies on teachers-students online communication, only little is known about the potential benefits and limitations of online treatments for at-risk youth. The goal of the current study is therefore to examine the characteristics of online therapeutic relationships between adolescents at risk and their caregivers (i.e., counselors and social workers). Specifically, the study addresses three research questions: (a) How do youth workers utilize social media communication for creating and maintaining therapeutic relationships with at-risk adolescents (b) What are the potential therapeutic benefits of such communication and what distinguish it from traditional face-to-face relationships with at-risk youth? (c) What are the problems and challenges that arise from these online practices? Altogether, by providing pioneering answers to these questions, we hope to promote the emerging interdisciplinary research filed of online counseling and contribute to the mental health of adolescents at risk around the world.

A qualitative research design was applied due to the exploratory nature of this research (Creswell, 2009 ). The study included 17 in-depth interviews (10 women and 7 men) with youth caregivers who work in a range of facilities and programs for youth (Table 1) , including welfare departments and boarding schools in isolated settlements in the eastern border of Israel. Participants were recruited in several ways: by contacting welfare departments in the research area, using the snowball method with the help of personal acquaintances, and posting messages on social media to identify potential participants. After collecting the contact information of potential participants, a personal inquiry was sent to them, which included a description of the research topic and its objectives. From among those who agreed to participate, we made an effort to create a research group with as wide a range of faculty positions as possible.

The interviewees were: youth counselors and coordinators (N = 7), social workers (N = 7), a clinical psychologist (N = 1), a director of social welfare services (N = 1), and a senior coordinator responsible for the training of faculty (N = 1). For details of the interviewees, see the table in Appendix 1. The age of the participants ranged from Focusing on the perspective of the therapeutic professionals provides a broad perspective of the phenomenon, including therapeutic, institutional, and organizational aspects.

Data collection consisted of semi-structured in-depth interviews conducted with the purpose of exploring the personal perspectives and experience of the interviewees, through the presentation of their authentic voices regarding the phenomenon under investigation (Moustakas, 1994 ; see also Marwick & Boyd, 2014 , on the use of interviews to reveal insights regarding new media functions in daily life). The interviews were conducted over the course of three months during 2019, with each interview lasting between one and one-and-a-half hours. The interviews were mainly done in-person, with the exception of five interviews that were done over the phone.

Interviewees were asked a variety of questions about the content and characteristics of their online communication with at-risk youth, what considerations motivated them to choose social media as an aspect of treatment, and how they perceived the advantages and disadvantages of online communication in this context (For the full questionnaire, see Appendix No. 2). The interviews were recorded and transcribed.

The data were analyzed with individual profiling and thematic analysis: first, we crafted profiles of each interviewee, which "allows us to present the participant in context, to clarify his or her intentions, and to convey a sense of process and time, all central components of qualitative analysis" (Seidman, 2006: 119) ; second, we examined categories, patterns, and connections, trying to find a balance between within-case and cross-case analysis (King and Horrocks, 2010) . The thematic analysis mostly involved an inductive approach (themes emerged from and were grounded in the data), although self-presentation was defined as a priori theme. Third, the coded categories were conceptualized into broader themes.

While innovative researchers are increasingly using electronic methods for coding data (mainly for the second and third stages mentioned above), due to the small size of the sample we preferred to stick to the traditional method of manual coding (see: Basit, 2003) . Following King and Horrocks (2010) and Neves et. al, (2015) , we preformed three steps procedures: First, the main and second authors read the transcripts independently to identify categories and themes. Second, both authors coded together, using a label-coding scheme and tested for convergence. Third, the coded categories were conceptualized into broader themes. Finally, the third author sampled 35 per cent of the transcripts to determine reliability of the category coding: the inter-rater reliability for category coding was 90 per cent. The inter-rater reliability was calculated by counting discrepancies in category assignment between the coded transcripts of the two authors and the third author and by dividing them by the total category assignments Throughout the research, we attempted to remember the gap between our experience as researchers in understanding the phenomenon being researched and we also aware that the qualitative researcher's feelings and emotions serve as an analytical tool, as well as constituting an integral part of our scientific work (Allen, Orbe, & Olivas, 1999) . In order to improve the trustworthiness of the results we used strategy suggested by Lincoln (1985), we invited three of the informant to read a review first draft of the findings analysis and conclusions, and some of their remarks are even integrated into this paper. This, in order to create a dialog wherein "the subjects of the theoretical statements become active partners in the developing process of verification of knowledge" (Bauman, 1976, p. 106),

In the course of conducting the research and writing the results and analysis, special attention was given to ethical considerations. All interviewees received a written explanation of the research aims, methods and ethics (considering anonymity and confidentiality). In order to ensure the privacy and anonymity of the interviewees as well as that of individuals mentioned in work-related stories that were told during the interviews, the names of the interviewees appearing in this article have been changed, while maintaining their gender and professional role. In some cases, technical and biographical details have been changed from the interview transcript (Allmark et al., 2009 ).

The research was approved by the Ariel University IRB.

The primary impression that emerges from the analysis of the interviews is that therapeutic staff members view social media as an important and necessary tool in the treatment of at-risk youth.

The social media platforms that used the staff was mainly Facebook, Instagram, and WhatsApp.

All of the participants reported that they see great advantages in integrating these platforms into their daily social work and therapeutic practices. Some even defined this type of work as a "necessary skill." However, with the exception of several interviewees who work in a dedicated online setting (detailed below), the majority noted that because the use of this media channel for therapeutic purposes is new, their workplace does not have clear guidelines about it. As Daniella, a social worker at a boarding school for at-risk youth said: "The staff doesn't have agreed-upon rules, each person does what he wants to and chooses to do." The therapists noted that they are given a "free hand" when it comes to online relationships. The issues that commonly arise are concerned with questions of privacy, authority, and boundaries (for more on these issues, see below). Analysis of the interviews revealed four distinct purposes of online communication with alienated youth: (a) technical and organizational purposes; (b) familiarity and connection (c) monitoring potentially dangerous situations, and (d) therapeutic interventions.

Deepening contact with youth

Understanding the (online and interpersonal) youth culture

Defining the treatment time

The technical and organizational aspect is particularly seen in the use of WhatsApp groups among the therapeutic staff, as well as WhatsApp groups that include both professionals and the youth they are treating. Eleven interviewees mention that the WhatsApp serves as an easy and highly accessible platform for messaging, updating, and scheduling meetings. The diverse functions of WhatsApp, such as the ability to create groups and mailing lists, and to switch between interpersonal and group communication, allow for increased control and management. For example, the ability to easily send information and updates to a large number of people frees up valuable time for professionals to engage in educational and therapeutic work. Two of the youth care workers noted the feature of WhatsApp that allows them to see whether the recipient has read the message (this is a default setting in the application). The feature has become an integral part of their decision-making process about whether it is worth investing additional efforts in an outreach project aimed at recruiting as many youth as possible.

A core theme that arose from all of the interviews is the use of social media for purposes of integration, deepening familiarity, and establishing therapeutic relationships with the youth.

Analysis of the interviews revealed three types of potential therapeutic benefits of social media communication with youth at risk. Moreover, young people understand that the ability to use the distinctive language of the Internet, for example emojis and new phrases and terms, enables a conversation on equal terms, allowing them to express their feelings in their own language. This creates closeness and opportunities to build trust in their relationships. "I identify a kid who has an easier time expressing himself through messaging. It gives him the time and space to read my message and get back to me when its comfortable for him. It's especially helpful to me especially in the early 'courting' stage of the relationship," (Uri, social worker at a non-residential regional center for at-risk youth).

One interviewee noted a gender difference when it comes to social media communication:

"With boys, let's say, I see that it's easier to communicate with them through WhatsApp than in person. For girls, it seems to me the opposite, because they are more verbal. For example, we had a male teen who had a really hard time communicating, but it was easier to talk to him through WhatsApp," (Ella, coordinator at a youth outreach program).

When we asked the interviewees what exactly is on social media that allows the connection they describe, they highlighted specific features and characteristics of social media, such as the availability, accessibility, and computer-mediation of the text that help deepen the relationship and create an open and honest conversation. "There is something about messaging. Hiding behind the message allows you to feel comfortable and open, without facial expressions that convey judgment" (Leah, media coordinator at the department for youth development). Another interviewee mentioned a phenomenon he commonly encounters, a situation in which there is no way to contact the youth, for technical reasons: "I have encountered situations in which youth have a problem with their cellphones, usually because they don't have money to pay for the service, so they turn off their phones, and WhatsApp is the only way I have to communicate with them,"

(David, social worker at a boarding school for at-risk youth). These descriptions recall the quote from Uri, about the way online communication helps in the early stages of the relationship. In contrast to classic psychological treatment, therapeutic professionals working with at-risk youth take an approach of gradually getting to know each patient. The characteristics of online communication facilitates this practice and help overcome barriers that may impede success.

(b) Maintaining relationships. Social media enables staff members to keep in touch with youth whom they've worked with in the past. Facebook and Instagram, in particular, allow them follow the activities, personal lives, and achievements of 'alumni' months and even years after they stop communicating through the more intensive media outlets such as WhatsApp groups that were actively used as part of the treatment frameworks. At the same time, three interviewees noted that the WhatsApp groups they shared with the youth remained active for years after the formal treatment framework ended. "The group is still active from time to time. I find it moving that they make sure to send happy birthday notes when one of the youth or counselors has a birthday... It's nice to see that they care about each other and that they take a minute or two to send each other birthday wishes," (Roni, social worker in the department of youth development).

The importance of this connection is twofold. On the part of the staff members, WhatsApp allows them to 'stay in touch,' but they indicated that it goes beyond that. They said that being able to follow how alumni are integrating into ordinary life allows them to receive feedback, which one interviewee described as "getting closure." Seeing the results, the outcomes, helps reinforce their belief in the challenging work that they do. From the perspective of the youth, the online forum can serve as a mutual support network, and even as a possible opening for them to seek out advice and assistance as they navigate their paths:

"[The WhatsApp group] helps them keep in touch with the most meaningful group in their lives, that is, the people they were with when they went through a hard time at the very important age of 16 or 17. We see that even four years later, they'll arrange to meet up, and they share a common language that stays very much alive.

It's mainly social, but it can certainly be a platform for therapeutic work like monitoring or ongoing assistance or referrals for help. Recently, a lot of the youth who finished [our program] had no framework to be in, and we found jobs for them, we were able to help them," (Nurit, director of social welfare division for youth development).

(c) Understanding the (online and interpersonal) youth culture. The therapeutic staff's online presence helps them to get to know the personal world of the youth, bridging the gap between the adults (the therapeutic professionals) and the young people. Six interviewees that highlighted this theme, refer to two levels of acquaintance. This further familiarity with the youth is particular to the online sphere. Caregivers see their presence on social media as a way to better understand the online forums and to identify risks, such as bullying and inappropriate discourse. Sometimes they can even offer guidance in this new type of social space.

Social media offers a convenient platform for youth to share emotions and express their thoughts, feelings, and frustrations. Therefore, in addition to providing a forum for strengthening connections and becoming familiar with each other, the presence of therapy professionals in online forums has valuable potential for identifying signs of distress prevalent among at-risk youth.

Interestingly, this theme was raised by all of the interviewees, citing numerous situations in which signs of distress were first exposed online.

There was one girl who always posted questions about sexual harassment. It was very worrying. After each such post, I would send her a private message: 'Hi, I read your post. I would love to help you.' It was a gentle kind of outreach, because she was already big, 17 years old, which is a stage when they tend to want to share less, when there's a desire for independence. After a few times, she suddenly answered and we developed a connection, and it really helped. (Nurit, director of social welfare division for youth development).

Online communication venues seem to allow youth who are experiencing distress to express their feelings with greater ease, as compared to face-to-face meetings. The interviewees described a wide variety of online posts that drew their attention to the distress of those who wrote them,

whether the post was about the pain of a breaking up with a boyfriend or girlfriend, or a crisis with their parents, a depressive episode, social isolation, or even suicidal thoughts.

There was a post in which someone expressed signs of distress. Naturally, we showed it the social worker, and a tragedy was avoided. The girl wanted to commit suicide, she wrote all kinds of things like "I want to die," "I hate my life." Because of Facebook, we were able to save her. (Ariella, coordinator at a youth outreach program).

Use of social media is relevant to therapeutic professionals tasked with identifying and reaching out to marginalized youth. In the digital age, this type of work has expanded from the traditional "street search" to a new practice of online searches. Indeed, some welfare departments have established media departments and teams that seek to leverage online forums and social media as tools for identifying distress, as means for outreach to at-risk youth, and even to help by providing an initial response, as described in this quote:

The Orly, who works in the media department of a youth development program, emphasizes the potential of this tool to reach youth who typically avoid exposing their distress or actively seeking mental health support.

We can identify situations of distress on social media by spreading posts that reach young people and invite them to contact us. It's there that we see the ones whose pain is more internalized, who don't necessarily look like the ones out in the streets.

We're also often approached with questions about sexual identity, which means we are expanding our target audience.

Using social media to meet the needs of youth and provide them with emotional support was also noted by the most of the interviewees -about 14 in number. "Online media helps us locate the youth. There are situations in which we were able to achieve deep therapeutic discourse solely through online correspondence... [the internet] provides us with a vast therapeutic space." (Leah, media coordinator, department of youth development).

However, it is important to note that while there was considerable consensus among the interviewed professionals regarding the potential uses of online communication described above (technical and organizational purposes, making connections, and monitoring distress), the situation was different regarding its use in therapeutic interventions. Even those who to some extent supported such practices presented ambivalent positions, or at least qualified their statements.

When Leah (quoted above) was asked to give an example of online therapy, she noted a practice that enables youth to sit in the same physical space as caregivers, but chat with them online:

Choosing to conduct therapy sessions through the chat feature is comfortable for the youth. They feel more secure and more open to talking. Meaning, we can actually meet with someone and sit in the same room but still be communicating through the chat. The main thing is to give them the feeling that they are safe and can trust us, and that we are here to help in any way that's comfortable for them, at least in the beginning," 5 of the interviewees strongly emphasize that providing treatment online is a topic of debate among professionals in the field. One of them mentioned a heated discussion among the professional team about whether the word "therapy" should be used to refer to online communication, or whether it is merely a "supportive aid" for therapy.

Leah stated that she sees an online chat as a first step in the therapeutic process, but not as a practice that can stand on its own. Similarly, other interviewees said they did not consider it a replacement for traditional in-person therapy.

The 

In discussions with the interviewees about their actual work in the field, we found almost complete consensus in favor of using online communication as part of their therapeutic work. However, deeper investigation into the issue indicates that they decided to use it both because of its benefits and despite its limitations. Most of the interviewees (14 of 17) noted dilemmas and debates leading up to the decision to adopt online forums as part of their work and some grappled with these questions even while they use online communication. These dilemmas revolve mainly around two issues: the need to protect the privacy of caregivers and patients, and the difficulty of delineating the treatment time.

Privacy of therapists and youth. Some characteristics of social media include personal exposure and sharing by its users. This is the key to its therapeutic potential, and also presents one of the main challenges facing therapists. Disclosing caregivers' personal profiles to the youth they treat is seen as problematic. "My Facebook page includes family-related things. I don't know if they need to know everything," (Samuel, social worker at a youth support center). This concern also relates to the professionals' opinions on current events: "I write a lot about politics on Facebook. Often, I didn't feel it was right for them to be so aware of my opinions," (David, social worker at a boarding school for at-risk youth).

The privacy dilemma also touches on the need to respect the privacy of the youth being treated. Monitoring youth online has ethical as well as therapeutic implications. "Keeping track of them and being exposed to the things they do is sometimes problematic, because it is an invasion of their privacy. We use it, but are very careful. Most of them have trust issues, so I don't want them to think I've been following them [online] all day," (Julia, social worker and therapist at a youth development program).

Various aspects of the privacy dilemma were mentioned multiple times by the interviewees. On the one hand, they expressed a desire to initiate discussions with youth about issues to which the therapist was exposed while viewing their posts on social media. On the other hand, they worry that raising issues the youth did not choose to share directly with the therapist could cause them to avoid treatment, or cause a crisis of trust. The significant therapeutic potential that is inherent in information the therapist sees online must be considered alongside the invasion of the youths' privacy and the danger of violating the therapeutic contract. Most of the interviewees said they strive to find the proper balance.

On the issue of the online statuses to which we are exposed, there is a lot of information that can help us catch problems in time, such as suicide. We had a girl who showed all kinds of warning signs that she was suicidal, and we prevented it.

This can be confusing, but also helpful. It is a question of whether to invade their privacy and whether they want us to do that, while the post is also be a call for help.

It's between invasion of privacy and offering help. As we catch up with the gaps in technology advancement, we have to think about how to use online media as an essential tool. (Leah, coordinator in the department for youth development)

Defining the treatment time. Another potential disadvantage of using social media that bothered the interviewed professionals pertains to the question of defining the Therapeutic setting. The accessibility and ease of sending messages makes it possible for youth to contact therapists beyond working hours, at night or on weekends and holidays.

There is a disadvantage in the sense that, for example, they might send messages really late at night. It's more difficult to set limits online, so you need to define the treatment time. I had a case with a girl who asked me 'Why were you up at 4 in the morning?' because she saw on WhatsApp that I was online. You have to understand that they are on their phones all the time, and they see and pay attention to everything. This has many benefits for adolescents, but you also have to pay It is important to note that the interviewees who mentioned the difficulty in limiting the treatment time were not only relating to their personal experience of how their online presence required them to be available to the youth in their free time; the undefined time also potentially harms the youth.

Being friends on Facebook and Instagram with the youth may allow them to deepen and improve their relationship, but it also raises questions about authority and how the relationship is perceived.

There is a concern that the caregiver-patient or mentor-mentee relationship will be transformed, in the youth's perspective, into a relationship similar to their other social relationships. This concern is heightened in the case of online contact between therapists and patients of the opposite sex ("If, with boys, I deliberate a few times, with girls I am a million times more cautious," Omer, clinical psychologist at a youth development program).

In addressing this issue, four interviewees noted that defining the times during which they can be in contact conveys an important therapeutic message and improves patients' ability to accept delayed gratification (despite their potential availability). This skill can be beneficial to the youth in many areas of life.

Before I told them until what time I'm available, there were situations when I would receive notifications at night as well. I had to make a separation between work and my personal life. It's mostly for myself, but it's also good for the youth, who know I am there for them, but not constantly. This parallels reality, in that they learn that not everything is always accessible to them, and that it may not be possible to help them as soon as they want it, and it's from an empathic place, so they can understand what it's like out there in the world. (Julia, social worker and caregiver at a youth development program)

One of the interviewers emphasized that when defining their working hours with the youth, they clarified that these limits can be extended in urgent cases: "For example, I specify that I will answer until 6 p.m., and after that only if it is an emergency" (Yifat, a coordinator at the department of youth development,). Similarly, the very discussion with the youth about what is and is not considered an emergency also serves as a therapeutic opportunity:

I had a case a few months ago of a boy calling me at 9 p.m. I sent him a message asking if it was urgent. It turned out that his bike had been stolen, and he was very worried about how his father would respond to the theft (...). That is why I think there are gray areas, and a need for shared thinking about everything. (Leah, media coordinator at the department for youth development).

Another work-related challenge concerns the nature of communication through text messaging.

Interviewees gave examples of text messages that could be interpreted as more social and intimate than was their original intent. Added to this is the fact that such messages sent outside of working hours can diminish the status of the therapist as an authority figure and thus detract from the effectiveness of treatment: "The problem is that it turns into something social, and I am not sure I want to give the relationship that connotation," (Menachem, senior coordinator at a youth development program).

It emerged that questions related to defining the treatment time are a significant concern to the therapeutic professionals. They repeatedly emphasized that because of the novelty of using online forums, they have no regular use pattern and no definitive answers. The interviewees reiterated that they lack formal guidelines from their workplace about providing treatment to youth online. ("In terms of any general definition or expectation for employees -there is nothing.

Everyone decides on individual basis," Julia, social worker and caregiver at a youth development program.) It is evident that they are eager to receive training on how to effectively and appropriately communicate with youth via social media. Instead, their online work activity is characterized by trial-and-error, intuitive decisions, retrospective considerations, and sharing their deliberations with their colleagues. "Basically, we are still discovering all the problems and advantages of this tool," (Leah). Several interviewees mentioned the need to guide the youth regarding proper online communication with therapy professionals as well as a need to develop professional training for therapeutic staff who wish to work (also) through online technologies.

This sentiment is summarized by Yifat, a coordinator in the department for youth development:

There is no doubt that today's technological world is evolving and it is not really under our control. The youth are there, and so we must show our presence there as well. I think, and see, that there are many young people who can only be contacted through online networks. Despite the disadvantages communicating through screens, this is the situation, and it should be channeled towards good things.

Through online networks, trust is also created. There is something very powerful about entering their world and about its ways of reaching them and treating them.

Even if the relationship ends without them getting frontal treatment, I have been in situations where the communication helped and supported young people who were in distress.

The growing popularity of social media raised new opportunities for reaching out and supporting youth at risk. Using in-depth interviews with youth counselors and social workers, this study examined the characteristics of online therapeutic relationships between adolescents at risk and their caregivers. The interviews revealed that counselors and social workers generally hold a positive view towards online therapeutic relationships. They acknowledge the benefits of this new type of communication and recount its therapeutic successes. According to the interviewees, social media based communication contributes to maintaining a reciprocal, meaningful, and long-term contact with the at-risk youth under their care.

The qualitative analysis of the interviews reveals that online communication can facilitate and even improve the quality of the therapeutic relationship with at risk youth in three key areas:

(1) forming a trustful and positive relationship with detached youth and maintaining it over time;

(2) detecting early signs of dangers and distress; and (3) providing psychosocial counseling when

needed. Yet, the clinical picture is more complicated than these noted advantages. The interviewees expressed several concerns regarding the integration of new technologies into the traditional therapeutic practice and some even opposed to use of the word "therapy" in the context of online communication with at-risk youth.

The ambivalence regarding the use of new media as a legitimate therapeutic tool might derive from the fact that counselors and social workers usually rely on well-defined, theory-driven therapeutic approaches (e.g., cognitive behavior therapy, psychodynamic therapy). These approaches determine the specific settings that are required for a successful treatment and layout the specific therapeutic strategies that should be applied to achieve beneficial outcomes.

Nevertheless, it seems that, regardless of their theoretical background, all the interviewees acknowledged the importance of maintaining a continuous relationship with at-risk youth through online communication. This main theme can be understood through the prism of "common factors"

in psychotherapy (Castonguay, 1993) .

Even though different therapeutic approaches incorporate different set of values and practices, they also share common factors that contribute to the successful outcome of the treatment. For example, simply the beginning of a treatment may arouse patient's expectations for symptom relief, which in turn inspire hope and motivation to change (Arnkoff, Glass, & Shapiro, 2002) . And above all, all approaches highlight the therapeutic alliance as an essential condition for treatment (Pilecki, Thoma, & McKay, 2015) . The quality of the relationship between patients and therapists is one of most researched therapeutic component, which has been proven to significantly contribute to outcomes of treatments, independent of the specific type of the examined therapy (Norcross & Wampold, 2011) . Based on this perspective, it is understood why all the interviewees cherished the online communication. Regardless of their guiding approach, they all assume that a positive and trustful therapeutic alliance is a crucial factor in the treatment of at-risk youth. Some might even argue that the very relationship between the therapist and the adolescent is the therapy.

However, forming a solid therapeutic relationship with at-risk youth is not an easy task.

Youth at risk are not always inclined to cooperate with conventional therapeutic efforts and may prefer tactics of avoidance and escape (Kaim & Romi, 2015) . Many of them fear the negative stigma associated with seeking help and are worried that cooperating with the "adult system", will damage their image in the eyes of their peers (Ben Hur & Giorno, 2010) . These characteristics may explain why the new media attracted both the adolescents and the counselors and social workers. Apparently, some of the problematic aspects of online communication, such as the anonymity and the avoidance of direct face-to-face communication, are the very reasons that this form of communication "speaks" to adolescents at-risk. The (partial) anonymity encourages youth to share their inner feelings openly and helps them to overcome the psychosocial barriers mentioned above. It allows them to receive discreet psychosocial support (Barak & Dolev-Cohen, 2006; Dolev-Cohen, & Barak, 2013; Valkenburg & Peter, 2009 ), without fearing from real or imagined social sanctions (Friedman & Billig, 2018) . Some scholars even argue that this type of communication encourages the users to be honest and to express their "true selves" (Lapidot, Lefler, & Barak, 2012) .

Moreover, in the digital realm, the adolescent may feel less pressure to participate in the conversation. Without the pressure, she/he may feel more comfortable and less shameful (Ben Hur & Giorno, 2010) . He or she can choose to contact the therapist through textual communication, which in many cases, is perceived as a more convenient and protected channel of communication in which they can express their feelings and thoughts in their own language (Barak, Klein, & Proudfoot, 2009 ). Indeed, this form of communication requires therapists to let go of some of their rules and theoretical beliefs. Yet, it seems that the interviewees agreed that the benefit of online therapeutic relationships with at-risk youth outweighs its potential damage.

Aside from the potential benefits for the relationship itself, interviewees emphasized the new opportunities that aroused with regard to early detection of dangers and distresses. Early detection of distress can prevent worsening of the patient's emotional state and mitigate his or her emotional burden (Halfin, 2007) . This is especially relevant to youth, as many adolescents do not share their negative experiences, such as victimization of bullying or suicidal thoughts, with their adult caregivers (Rey & Bird, 1991; Velting et al., 1998) . This finding corresponds with the emerging line of research according to which mental health conditions can be traced from social media activities (for a review see: Guntuku, Yaden, Kern, Ungar, & Eichstaedt, 2017) . Although most of this research is focused on adults, promising results were also evidenced among adolescent populations (Ophir, Asterhan, & Schwarz, 2019) . The current study joins these new studies and suggest that social media has become an important source of psychosocial information about atrisk adolescents, offering a rare glimpse into their troubles and pain (Ophir, 2017; Ophir, Asterhan, & Schwarz, 2017) .

Finally, the interviewees highlighted the opportunity to provide counseling from a far.

Despite some reservations from online treatments, there is ample evidence that online counseling has a significant impact on patients, which in many cases is comparable to that of face-to-face counseling (Andersson, 2016; Mallen et al., 2005) . Studies showed for example that computerbased treatments are effective for both depressed (Kessler et al., 2009 ) and anxious patients (Barak, Hen, Boniel-Nissim, & Shapira, 2008) . The findings from the current study confirm previous research that claimed that online counseling increases accessibility to treatment (Mallen et al., 2005) .

Social media seem to increase the accessibility to youth who live in remote geographical areas and to youth who chose to distant themselves from their family and community. The therapeutic relationships that are formed online are especially relevant to these complicated times of social distancing due to the COVID-19. Moreover, aside from overcoming geographic limitations, social media seem to provide the adolescents subjective feelings of ease and comfort.

These feelings correspond with a well-acknowledged advantage of online counseling, in which clients may feel less threatened in their natural surroundings and allow themselves to be more exposed with their therapists (Gilat, Ezer, & Sagi, 2011) . These two factors, accessibility and comfortableness, can be critical when working with at-risk youth who tend to engage in defiant or rebellious behaviors.

Despite these advantages, online counseling suffers from several principle drawbacks:

First, it reduces the ability of patients and therapist to interpret nonverbal communication signs and messages are sometime ambiguous (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Suler, 2008) . Second, it might diminish the caregiver's ability to provide empathy and warmth. Third, it may feel less binding for some patients could easily dropout from the treatment (Amichai-Hamburger, et al., 2014) . Fourth, it raises practical and ethical dilemmas, especially when the therapeutic relationship is form via social media (rather than video-chats, such as Zoom or Skype).

Therapists and counselors may ask themselves: What distinguishes me from other "Facebook friends"? Should adolescents be exposed to my personal photographs? And will they expect me to be available to them online at all times?

These dilemmas are not unique to youth care workers. Previous literature that addressed teacher-students online relationships raised similar concerns. Although many teachers acknowledge the benefits of social media communication, they are also worried that it will undermine their authority in the eyes of their students (Asterhan & Rosenberg, 2015) . Even those teachers who used social media to communicate with their students, were concerned about privacy boundaries and were worried that their relationships with the students will become too personal.

Like teacher, youth caregivers, as shown in this study, are not naïve. They are well aware of the potential pitfalls of social media interactions. Despite the inherent informality that characterizes their work with at-risk youth, they do not see their relationships with youth at risk as symmetrical relationships. A primary challenge in this context is the need to understand and define the physical and emotional boundaries between them and their patients (Friedman & Billig, 2018; Haenfler, 2004; Nagata, 2001) . Several interviewees noted difficulties in defining such boundaries, including the therapeutic space, the duration of the treatment, the availability of the therapist, and the privacy of both patients and caregivers. Thus, future training programs should consider intrinsic characteristics of computer-mediated communication, such as the blurred boundaries and its relatively democratic and egalitarian nature (e.g., Asterhan & Eisenmann, 2011; Hampel, 2006; Weasenforth, Biesenbach-Lucas, & Meloni, 2002) .

Without minimizing these concerns, the main conclusion from this study is that youth care workers are well aware of these challenges and yet they all agree that these challenges should not stop them from leveraging the new media for psychosocial purposes. They make considerable efforts to navigate these challenges by clearly defining the online practices that could contribute to the therapeutic process and avoiding or minimizing the ones that could disrupt it. However, they still lack appropriate training and usually work their way to the at-risk youth through trial-anderror.

The current study has limitations. The first limitation concerns the fact that we only interviewed adult caregivers and the youth perspective is missing. Moreover, the caregivers might have different perspectives and attitudes towards technology-based communications, due to generational difference (Zhitomirsky-Geffet & Blau, 2016) . In Israel most professional caregivers only start their practice in their late twenties. Most of the interviewees in this study therefore belonged to generation Y (aged 23-41). They are still considered very technology oriented (compared with previous generations) but they might have more complex attitudes towards internet-based communication, compared with the youth at risk (who belong to generation Z and received their first smartphones as children). These differences in attitudes towards technology may have an impact on the online therapeutic relationship. Yet, we note that all interviewees emphasized the importance of integrating online communication in their work and declared that digital literacy is a required skill when working with youth.

A second limitation concerns the location of the study. Two specific contexts may limit the generalizability of the findings: the country (Israel) and the socio-geographic location (east border). Therapists in Israel may differ from therapists in other countries (e.g., in Israel, therapists are allowed to provide online counseling, without formal training in this field) and youth in the east border may have different challenges than youth in other places (e.g., ideological crisis that reflects the tension between their conservative upbringing and their new identity). We therefore recommend that further research and future training programs would consider cultural differences.

A third limitation concerns the fact that the study is based on qualitative interpretations of interviews with counselors and social workers. The exploratory nature of the study calls for future works that will build upon the current findings and establish the benefits of social media therapeutic interactions. Further studies are recommended to quantify these potential benefits and explore their reliability overtime and in additional contexts. Studies should also examine the perspectives of the youth themselves and compare them with those of their caregivers. There is also a need to examine potential confounding factors that might impact the online therapeutic relationships, such as gender differences (Noguti, Singh, & Waller, 2019) , generational differences (Hargittai, 2010) , cultural contexts (Mesch & Talmud, 2008) , and religious contexts (Rosenberg, Blondheim, & Katz, 2019) . These factors might affect the very legitimacy of the online relationship. It is recommended that the current findings will be further examined thorough a quantitative and wide-ranging research.

Despite these limitations, the current study suggests that the new communication technologies are bringing viable and exciting opportunities to the field of youth at risk. Most interviewees believe that online therapeutic relationships are beneficial for at risk youth as they help to maintain a trustful relationship with detached youth and provide a platform for early detection of distress and for delivering psychosocial counseling. Yet, as noted above, the clinical picture is more complicated than these advantages. Thus, it is advisable to provide special training to youth caregivers to help them bridge the gap between traditional and online practices and help them provide an effective treatment to at-risk youth online. 

Is online communication discussed with you at work? Are there certain procedures or guidelines set by the council with regard to social networks? Have you undergone training on this topic?

what do you do with this information? 14. Do you have joint WhatsApp groups with the youths? Do you have one group for all of them? What is the role of the group? What do you do there? What interaction takes place there? What are the advantages and disadvantages of these WhatsApp groups? 15

Ethical issues in the use of in-depth interviews: Literature review and discussion

The future of online therapy

Internet-delivered psychological treatments

Expectations and preferences

The promise, reality and dilemmas of secondary school teacher-student interactions in Facebook: The teacher perspective

Does activity level in online support groups for distressed adolescents determine emotional relief

A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions

Defining internet-supported therapeutic interventions

Why shy people use instant messaging: Loneliness and other motives

Manual or electronic? The role of coding in qualitative data analysis

Narrowing the adolescent service gap: Counseling and mental support for adolescents on the Internet -Yelem as a representative case

Common factors" and "nonspecific variables": Clarification of the two concepts and recommendations for research

Research design. Qualitative, quantitative, and mixed methods approaches

Adolescents' use of instant messaging as a means of emotional relief

Teacher-student relationship and SNSmediated communication: Perceptions of both role-players

Education, socialization and community: Coping with marginal youth in rural frontier communities in Israel

Seeking help among adolescents: Their attitudes toward online and traditional sources

Detecting depression and mental illness on social media: An integrative review

Learning, teaching, and scholarship in a digital age: Web 2.0 and classroom research: What path should we take now? Educational researcher

Gender and ethnic differences in formal and informal help seeking among Israeli adolescents

Depression: the benefits of early and appropriate treatment

Rethinking sub-cultural resistance: Core values of the straight edge movement

Digital na(t)ives? Variation in internet skills and uses among members of the "net generation

Student-teacher relationship in the Facebook era: the student perspective

WhatsApp is the message: Out-of-class communication, student-teacher relationship, and classroom environment

Adolescents at risk and their willingness to seek help from youth care workers

Therapist-delivered internet psychotherapy for depression in primary care: A randomised controlled trial

Effects of anonymity, invisibility and lack of eye-contact on toxic online disinhibition

Online counseling: Reviewing the literature from a counseling psychology framework

Networked privacy: How teenagers negotiate context in social media

Qualitative research design

Cultural differences in communication technology use: Adolescent Jews and Arabs in Israel

Facebook enhances antidepressant pharmacotherapy effects

Phenomenological research method

Beyond theology: Toward anthropology of "fundamentalism

The 'Non-aligned' Young People's Narratives of Rejection of Social Networking Sites

Gender differences in motivations to use social networking sites

Evidence-based therapy relationships: research conclusions and clinical practices

SOS on SNS: Adolescent distress on social network sites

Unfolding the notes from the walls: Adolescents' depression manifestations on Facebook

The digital footprints of adolescent depression, social rejection and victimization of bullying on Facebook

In times of war, adolescents do not fall silent: Teacher-student social network communication in wartime

Cognitive behavioral and psychodynamic therapies: Points of intersection and divergence

Sex differences in suicidal behaviour of referred adolescents

Youth at risk: Definition and implication for service delivery

WhatsApp, teacher?": Student perspectives on teacherstudent WhatsApp interactions in secondary schools

It's the text, stupid! Mobile phones, religious communities, and the silent threat of text messages

A virtual safe zone: Teachers supporting teenage student resilience through social media in times of war. Teaching and Teacher Education

Techniques to identify themes

Image, word, action: Interpersonal dynamics in a photo-sharing community

Social consequences of the Internet for adolescents: A decade of research. Current directions in psychological science

Parentvictim agreement in adolescent suicide research

Cross-generational analysis of predictive factors of addictive behavior in smartphone usage

Characterization of youths with whom he works: What is the youths' background? What is the number of youths; their age range, place of residence; characterization of youths according to the family they came from; in which frameworks did they spend time in the past; do they have a delinquent background; did they undergo molestation as children or another form of victimization. Are they in a formal framework, or not? If not, what do they do in their free time?

To what extent do the youths reveal their personal lives to you? Are they cooperative?

What types of problems do you encounter when working with them?

Are the youths in contact with their families? If so, in what way is this contact expressed? What is the frequency of the youths' contact with their families, do they feel respect towards them or hatred and anger?

What types of problems do the youths that you encounter generally suffer from? (e.g., personal problems, family, social, certain extreme behavior.) Focus on drugs, crime, behavioral disorders -bullying, attention disorders, depression and anxiety -have they been hospitalized or expressed suicidal tendencies?Section B -Working with the Youths and Online Communication

The nature of the work and dynamics of the connection between the youth and the social workers? Where do you actually meet them? Are they obliged to attend some of the meetings and what do you do if they fail to come? What are the most common modes of treatment?

To what extent are you exposed to what youth at risk do on social networks?

What characterizes this use? What applications do they like in particular? What do they reveal on the network? (network advantages and disadvantages for the youth)

To what extent are you involved in the youths' social network world and in what ways? (e.g., follow them on Instagram, friends on Facebook, etc.?)

Where you work, is it legitimate to communicate with youths via the networks or even make contact with them? (e.g., WhatsApp groups or Facebook friendship requests? If so -for what purposes?

Do you learn more about their world thanks to the network? Do you use it as a tool for making personal contact with them? Are you active on the social media networks, and how much do you know about using these networks for your personal needs? 

 Counselors and social workers hold a positive view towards online therapeutic relationships  Social media improve the therapeutic staff's capabilities  positive practices related to distinctive features of online communication channels  significant challenges included dilemmas regarding privacy, authority and boundaries