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Issue two November 2010

Online Mindfulness-based Therapy: Convenient, Effective, and Affordable PAGE 34

Communication and Spiritual Autobiography

Means and Methods For Telling Your Story PAGE 9

Life 2.0

Virtual World, New Reality PAGE 20

Second Life

A Virtual Playground for Therapists, Creativists, Healers, Educators, and Everyone Else PAGE 31 PLUS...

Legal Briefs, Cybersupervision, Marketing Toolbox and much, much more...

TILT - Therapeutic Innovations in Light of Technology TILT is the magazine of the Online Therapy Institute, a free publication published six times a year online at ISSN 2156-5619 Volume 1, Issue 2, NOVEMBER 2010 TILT Magazine Staff Managing Editors Kate Anthony & DeeAnna Merz Nagel Magazine Production Coordinator Agnes Ikotun Magazine Design and Layout Delaine Ulmer Magazine Advertising Manager Betsy Schuff Associate Editor for Research Stephen Goss Associate Editor for Innovations Mark Goldenson Associate Editor for Supervision Anne Stokes Associate Editor for Marketing and Practice Building Susan Giurleo Associate Editor for Film and Culture Jean-Anne Sutherland Associate Editor for Legalities Jason Zack Advertising Policy The views expressed in TILT do not necessarily reflect those of the Online Therapy Institute, nor does TILT endorse any specific technology, company or device unless Verified by the Online Therapy Institute. If you are interested in advertising in TILT please, review our advertising specs and fees at Writer’s Guidelines If you have information or an idea for one of our regular columns, please email with the name of the column in the subject line (e.g. Reel Culture). If you are interested in submitting an article for publication please visit our writer’s guidelines at

TILT is about envisioning therapeutic interventions in a new way. While Kate was visiting DeeAnna on the Jersey Shore, they took a late afternoon boat ride and a display of sail boats tilting against the sunset came within view. It reminded them how, as helping professionals, we should always be willing to tilt our heads a bit to be able to envision which innovations – however seemingly unconventional – may fit our clients’ needs. Our clients are experiencing issues in new ways in light of the presence of technology in their lives. As helping professionals, so are we. TILT and the Online Therapy Institute is about embracing the changes technology brings to the profession, keeping you informed and aware of those developments, and entertaining you along the way.

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9 Communication and

Spiritual Autobiography Means and Methods for Telling Your Story

20 Life 2.0

Virtual World, New Reality

31 Second Life

A Virtual Playground for Therapists, Creativists, Healers, Educators, and Everyone Else

34 Online Mindfulnessbased Therapy:

Convenient, Effective, and Affordable

Issue in every


News from the CyberStreet

12 Research Review

18 What Would You Do?! 19 Wounded Genius

27 Reel Culture

28 Legal Briefs

38 A Day in the Life

40 CyberSupervision

44 New Innovations 46 Marketing Toolbox

49 Look Who’s Verified!

50 For the Love of Books 52 Advertiser’s CyberMarket

A Note From the Managing Editors… Welcome, or welcome back, to TILT – Therapeutic Innovations in Light of Technology – for our 2nd Issue, which we hope you enjoy every bit as much as the last one (or more!). We had great feedback to the premier issue – many thanks to everyone who took the time to comment and congratulate us on it. Our aim continues, issue by issue, to keep you up-to-date with developments in innovations in service delivery; publish interesting articles; provide resources; feature members and friends of the Online Therapy Institute; and include a dose of humour along the way from our resident cartoonist, Wounded Genius. All our regular columnists are here, with useful and entertaining comment on research; online supervision; marketing; film culture; legalities; and new innovations. We also have our member’s responses to our last Ethical Dilemma, and a new one for you to consider and to post responses at our social network forums for publication in Issue 3. Our featured online therapist member this month is Geoff Cox from the UK, who recently was awarded verification through the Institute’s Get Verified programme. We also have two more books to share with you: Jean-Anne Sutherland (who writes our Reel Culture column) and her colleague Kathryn Feltey have a very interesting book titled Cinematic Sociology: Social Life in Film which takes readers beyond watching movies; it helps them “see” films sociologically and develops critical thinking and analytical skills that will be useful in college coursework and beyond; and David Diana’s Marketing for the Mental Health Professional: An Innovative Guide for Practitioners. We have four articles for you this month: Peter Strong writes on his experience of the usefulness of Mindfulness-based Online Therapy, using predominately videoconferencing among the other blended technologies such as email. Neila Miller (aka Marly Milena in Second Life) describes the group coaching sessions she holds in the virtual environment, often using Gestalt theory on which to base her virtual work. Alisa E. Clark tell us of how she works with Spiritual Autobiography using new technologies; and finally we, the editors, offer you an article about the film Life 2.0, a documentary which follows people for a period of over a year or more as they manoeuvre life lived in a mixed reality. We hope you enjoy our second issue, whatever professional world you inhabit. All feedback is heartily welcomed at the OTI social network!

Managing Editors

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TILT – Therapeutic Innovations in Light of Technology

NEWS from the

CyberStreet The Cyberstreet is here to keep you informed of news even if you haven’t found time to visit the Online Therapy Institute Website or Social Network!

And remember, even if you are not on Twitter, you can still read member tweets at the homepage of!


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Blog news… Here is a glimpse of what is going on…get a taster and then head to and the blogs at for more! DeeAnna gives an update on the Florida Certification Board’s (FCB) new Certified E-Therapist (CET) designation and certification. A review of the Online Therapy Institute’s recent Town Hall meeting in Second Life, with Kate and DeeAnna along with John Wilson from We talked about resources for people interested in online therapy and the influence of technology on the mental health field. In just a few days we had 25 people sign up for the free event. The blog gives a list of further resources for members. Kate and DeeAnna presented at 2VCC in Second Life. We facilitated a Q&A with Jason Spingarn-Koff, director of the movie Life 2.0. Demonstrating Cyberculture through Film: Life 2.0 discusses how Jason’s documentary about Second Life can increase cultural competency among counselors, psychologists and other helping professionals. See the article in this Issue for a full report! Great information about online testing and assessment, reproduced with kind permission from Anthony S. Ragusea, Psy.D. via email to several professionals inquiring about this topic. You can read this information at the Blog as well, and visit his profile at the Online Therapy Social Network. Over at the social network blogs, Upaya Psychotherapy are doing a small survey on communication between therapists and their professional organisation; Mieke Haveman sends a link to her blog about her experience during the Institute’s Open Office Hour in Second Life; and Alisa E. Clark writes on the use of Spiritual Memoirs, and expands on this theme later on in this Issue.

Member news… "Crash Course in Social Media for Mental Health and EA Professionals" on December 3, 2010, from 8:30 am to 4:30 pm at the Council on Alcohol and Drugs in Houston, Texas. For more information, and to register visit http:// Free training event: Laura Dessauer is conducting a complimentary training for therapists in private practice on: “Therapy Practice Breakthroughs: 9 Powerful Strategies to Creating a Thriving Therapy Practice Helping More People and Increasing Your Income”. For more information and to register, visit T I L T MAGAZ I N E nov e m b e r 2 0 1 0


TILT – Therapeutic Innovations in Light of Technology

Barbara Cunningham, MFT is the author of a chapter entitled A Systems Treatment of an Impaired Physician Family in an updated academic text. The text is published by PRO-ED Inc and is entitled ALCOHOLISM AND SUBSTANCE ABUSE IN DIVERSE POPULATIONS, second edition, edited by Drs. Gary and Ann Lawson (2010). Visit her web site at http://, a free online office for therapists, won the Vator Splash startup competition in Silicon Valley. The competition fielded over one hundred internet startups but was unanimously selected by the investor judges and won the popular audience vote. Raj Kapoor, partner at the Mayfield, said Breakthrough's strategy of working with health care payers was a smart strategy. Gideon Yu, former CFO of Facebook and current partner at Kholsa Ventures, said, "This is an enormous market." Lora Sasiela featured in the November issue of Marie Claire, as their “money therapist” – read the article here: advice/tips/money-shrink-makeovers. Arthur Ciaramicoli has written a new book called “The Curse of the Capable: The Hidden Challenge to a Balanced, Healthy, High Achieving Life”. The book focuses on 4 stages to change your story and discover greater love, health and success. It is filled with poignant stories of his clients who have learned to re-write their story and gain greater emotional freedom. Please visit the book’s web site www. or Arthur’s personal site The International Society for Mental Health Online has announced the development of the ISMHO Academy. The ISMHO Academy hosts ongoing free educational events within their forums for members to discuss online mental health issues and enrich their scope of work with innovative approaches to the use of online technology in the field. ISMHO welcome your comments, discussion, and questions, in their forum. To access the ISMHO Academy, please log into www., click on Our Forums, ISMHO Educational Presentations.


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Recruitment… Psychologist or Psychotherapist Location: online / worldwide is one of the world's most international online therapy and counseling websites. At this moment we're growing very quickly and would be interested in hearing from qualified psychologists or psychotherapists who would like to work and grow together with us. Work home-based, online, part-time. Our service is available in 8 languages as of today. This call is open for applicants who speak English, Portuguese, French or Swedish. Many thanks for your interest. Please visit our website for further details. Therapion - http://www.

The ISMHO is also currently requesting nominations for the 2011 slate of their Executive Board. Nominees must be current ISMHO members, and may be suggested via email to the 2010 Past-President: Robert Hsiung, bob@, by November 15, 2010.

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Communication and Spiritual Autobiography: Means and Methods for Telling Your Story Alisa E. Clark

Today the means and methods for telling your story have exploded. There are endless ways to communicate your journey to many people with just a little effort and inspiration. Sharing your spiritual story is no longer a lofty goal. Instead, the world is waiting to hear your testimony and you have the means to offer it. Communication has changed the ways we can impact the lives of others with our stories. We can heal, change a life and change the world by letting others know that they’re not alone. All we need to do is choose to share.

L Have you ever been comforted by a friend as they told you something you never know about them? Did you ever discover that someone's life was changed because you took the time to say, "I've been where you are"? How many times have you found God in a simple story told by a caring friend? Everyone has a spiritual story. Not all journeys are the same but every life if full of stories of growth, change, hope and encouragement. Every individual has a journey to share and today there are endless means for sharing it. Today spiritual autobiography (or spiritual memoir) is for everyone. The world is full of stories that can, and must, be told! It hasn't been long since the avenues for sharing your life story were limited. Powerful stories would be told occasionally at meetings, in church-

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es or at events. Others may have published short articles that gave away bits and pieces of their lives in local newspapers or magazines. If you got really lucky your testimony might make it to the bookshelves at the local bookstore. Even more unlikely was the opportunity to share on television or through the words of a radio program. Getting your voice to reach those who needed to hear it was a long shot. Today the means and methods for telling your story have


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exploded. There are endless ways to communicate your journey to many people with just a little effort and inspiration. Sharing your spiritual memoir is no longer a lofty goal. Instead, the world is waiting to hear your testimony and you have the means to offer it. Communication has changed the ways we can impact the lives of others with our stories. Just about anyone can publish their spiritual autobiography in a large variety of formats. Print on demand publishing allows you to

publish your memoir with little financial risk and big influence. Ebooks allow you to reach even more people with even less financial strain. An internet search on self publishing will connect you with a lot of opportunities. While some of these opportunities might not be right for you, there's a good chance you will find a good fit. Don't take the first offer you get. Ask a lot of questions and do your research: writers beware! Learn the difference between Vanity Publishing, Subsidy Publishing, Hybrid Publishing, Traditional

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Publishing and Self Publishing. Careful research will allow you to find a publisher who will meet your needs. Maybe writing a book is not the means you would like to use to share your testimony? Writing a book was once among the few ways to get your message out. The internet has turned this reality around. Anyone can have a Facebook Page, start an on-line social network, Twitter about their journey, join a discussion group, become part of a forum or start their own blog. A whole life can be shared from beginning to end with the use of these social networking tools. These are user friendly tools that anyone can learn about. Getting started is easier than you think and there are tons of forums and discussion groups waiting to help you if you get stuck! Don't be bashful about using these resources to help you reach those who need to hear your testimony. Don't let the unknown stop you from reaching those who need the encouragement and hope your story has to give. Once upon a time only the rich and famous could be seen on a screen. Web sites like UTube, SlideShare and Flickr have changed that. Now you can upload your own testimony on video for thousands of viewers to see. Photographs, Power Point displays and slide shows that convey your journey can be made readily available for a large viewing audience. Today your testimony has more power than it ever has. Even if you don't own a computer the local library now has one for you to use. Just about anyone can reach anyone through the internet. No more excuses! You have unending methods for getting your message out. Spiritual autobiography is a powerful tool of encouragement and hope. Someone out there needs to know they are not alone. Your spiritual memoir has the power to bring comfort and joy to someone that needs some. Perhaps ten years ago you doubted that your journey could reach anyone so you didn't bother to share it? Realize that today is a new day. Find a way to share your testimony and get it out into the world

as a touch of God for someone who needs it. There are endless means and methods for telling your story. Today can become the day you begin to share! FURTHER READING J.W. Pennebaker and C.K. Chung, "Expressive Writing, Emotional Upheavals, and Health," in Handbook of Health Psychology, ed. H. Friedman and R. Silver (New York: Oxford UP, 2007), 263-84. Pennebaker/Reprints/Pennebaker&Chung_FriedmanChapter. pdf

About the author Alisa E. Clark believes in the power of spiritual autobiography. Her website invites viewers to create and share one's own spiritual memoir and allows readers to learn more about Alisa's own spiritual autobiography: Dancing in the Doghouse. You can learn more by visiting

TILT – Therapeutic Innovations in Light of Technology

R e s e ar c h R e v i e w

Virtually Ideal Virtual Versions of the Real


ould you want to live in a near-ideal virtual reality? In an interesting, although informal, survey study, the Institute for Ethics and Emerging Technologies (IEET) reports that among a selfselected sample of its readers (n=349), 14% would want to spend all their time in a virtual reality, if it could be made close to an idealised version of the kind of thing we are familiar with from Second Life and similarly immersive artificial environments. A little more than 20% more indicated that they

would want to be there most of the time, only visiting real reality from time to time. While nearly 1 in 3 said they would have little or no interest in even a nearly perfect virtual reality – and a similar proportion said they would split their time between that and the real world – there is clearly a significant minority who would be interested in leaving everyday reality behind completely in favour of a simulated version. The study authors

If it was near-ideal, how much time would you spend inside virtual reality?

(Illustration and data reproduced by kind permission of the authors.) Source: IEET website, 12th August, 2010 [Accessed 6th October 2010]. Available at


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S t e p h e n G o ss speculate on how these proportions would change if (or when) the option of living in near perfect virtual worlds becomes a reality. It may also be that people who did not choose to be part of the survey group would be less enthusiastic. Commentator Koen de Paus, from Belgium, said that he would like to see the study replicated with a more representative sample, “but I am afraid the outcome will be the exact opposite of this poll and that the general view of a virtual world will be negative.” While just how representative this selfselected sample of convenience (mostly English speaking and from Europe or North America) would be of the general population remains a moot point. But given the rise in popularity of so many virtual environments from computer games to worlds like Second Life, the extent to which a person might choose to immerse themselves once the experience becomes “near-ideal” is intriguing. As the film Life 2.0 vividly demonstrates, it is already possible for virtual living and relating to have farreaching effects on all of a person’s life, virtual or otherwise. Older age groups join the “i-Generation” Following on from the article in the Premier issue of TILT by Marina London, it is interesting to note that the “i-Generation” can no longer be thought of as only being composed of the young. While social networking use has been increasing rapidly in recent years, older age groups have been catching up on their younger counterparts. Between April 2009 and May 2010, use of social networking among 18 – 29 year olds grew by just 13% (partly because so many were already making full use of

it), while in the 50 – 65 age group it grew by 88%. Among the over 65s it doubled (i.e. grew by 100%). A recent report by the Pew organisation states that “half (47%) of internet users ages 50-64 and one in four (26%) users age 65 and older now use social networking sites”. While the total proportion of older Internet users who access social networking sites is still some way behind that of younger age groups, the many ‘silver surfers’ still preferring email to Facebook, “at the same time, the use of status update services like Twitter has also grown— particularly among those ages 50-64. One in ten internet users aged 50 and older now say they use Twitter or another service to share updates about themselves or see updates about others” (Madden, 2010).

References Madden, M. (2010) Older Adults and Social Media. Social networking use among those ages 50 and older nearly doubled over the past year. Pew Internet and American Life Project. August 27th, 2010. [Accessed 6th October 2010]. Available at:

Please send reports of research studies, planned, in progress or completed, to, Subject line: Research Review.

Stephen Goss, Ph.D. is Principal Lecturer at the Metanoia Institute, and also an Independent Consultant in counselling, psychotherapy, research and therapeutic technology based in Scotland, UK.

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Research website

Allie Ken is conducting research into how counsellors observe relational phenomena emerging in online counselling practice. The research seeks to explore the online counselling relationship, examining the practice and process of being an online counsellor 'in relationship'. In particular, she is interested in how online counsellors experience relational phenomena emerging in online practice, and furthermore if and how they adapt their model in order integrate it with their online clinical work. Participants will need to be available for brief, semi-structured interviews in the UK in November and December. If you think you might be able to help and would like to find out, contact her confidentially.



Konstantina Tsalavouta, a Counselling Psychologist in Training at the University of East London, UK, is recruiting participants for her study to explore the experiences of people who offer online counselling services. She is interested in how the therapeutic relationship is developed and maintained online; how therapists experience it; how they process factors important for the therapeutic work such as empathy and support; and the working alliance/therapeutic collaboration between client and counsellor.



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TILT – Therapeutic Innovations in Light of Technology

Reader Responses


You attend the annual conference for your professional association and meet up with colleagues you have not seen in a while. Your quiet night with a few friend turns into dinner, drinks, conversation and reminisce. You had such a great time! When you return home and check email you find several posts are waiting for you on your Facebook wall. You login to Facebook and see that you and your colleagues tagged in several “questionable” photos. The pictures reveal your fun night out and not necessarily from your most professional angle! What Would You Do?!

Can people untag themselves? If so, start there! Then I'd have a conversation with the person who posted them about the pictures and negotiate an understanding about taking them down/ asking permission in the future, etc. I'm assuming this person is a friend based on the above description, so that conversation shouldn't be too painful....

Reply by

Susan Giurleo


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What would I do? Well for starters, my business and personal facebook pages are separate. On my business page, I do not allow for the posting of photographs. Not for concern about photos of myself, but I have seen the posting of porn to friends and colleagues pages lately and don't want that to happen on my business page. On my personal page, I am quite selective as to who is added as a 'friend'. If I have added these colleagues to my personal profile, then the tagging of photos is permitted. But, I limit the mix of business and personal. In addition to that, I try my best not to get into 'questionable' situations. In this era, when all that you do is public, it is up to everyone to only do in public what they want EVERYONE to see and know. So, therefore, I have done things beforehand to prevent getting into such a dilemma.

Reply by

Relationship CafĂŠ

Accept that I’m human.

Reply by

Jo Winfrey

There are a few ways to handle this. Privacy settings on FB now are such that you can select who can and cannot see the photos. You can begin by grouping individuals that you do not want seeing the photos in a group of their own. You can also, as Susan mentioned, remove tags that identify you in the pictures. Something that also comes to mind is - where do you draw the line between being 'social' and being 'professional'? When you go to a conference or training you are meeting with colleagues and professionals in your field. I feel you have to be at your best behavior when interacting with them. After all, our social network is how we promote each other. This is how we get referrals and recognition in our communities.

Reply by

Belky P. Schwartz

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TILT – Therapeutic Innovations in Light of Technology

In each issue of TILT we shall be presenting an ethical dilemma about a Web 2.0 experience and other ethical topics related to mental health and technology, and inviting readers to comment at the Online Therapy Institute’s social network. In the following issue of TILT, we shall publish a selection of comments about what YOU would do when faced with the dilemma.

What Would You Do? Here’s the dilemma You are an online therapist who has received an Intake form from a potential client. The Intake form states that she requires help with what she considers to be an "internet addiction". She states she barely leaves the house, as she does all her shopping, socialising and work online running a small Ebay service. She spends many hours in World of Warcraft and Second Life. She wants online therapy for her addiction so that she "never has to leave the house or see anyone again" while in treatment. What would you do?! Weigh in at the OTI Social Network’s discussion forum! topics/ethical-dilemma-what-would-you


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Wounded Genius Welcome to our Resident Cartoonist, Wounded Genius. We discovered WG through Facebook, when our colleague and friend Audrey Jung posted a cartoon on Facebook, and within half an hour we were chuckling away, following on Twitter, and were commenting on the main blog at - make sure you check out the archive of cartoons, written from the perspective of a client. We are thrilled to have WG on board, both for TILT and as a member of the OTI social network.

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2 e Lif a u t r i V w e N LIFE 2.0 Director Jason Spingarn-Koff’s avatar, Jay Spirer

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0 . 2 , d l r o W l a y t i l a Re el g a N a n DeeAn ony h t n A te and Ka

In Life 2.0, a new documentary, director Jason Spingarn-Koff follows people for a period of over a year or more as they manoeuvre life lived in a mixed reality. DeeAnna attended a screening at the IFC Center in New York during their Stranger Than Fiction season, and Kate attended the premiere at the British Film Institute (BFI) in London, in May and August respectively. The film is an intimate look into the lives of three people who are brave enough to share their stories from their experiences in virtual reality environments.

One of the scenarios is that of two people - each married to someone else - involved in a cyberaffair, virtually entwined from hook-ups in Second Life to using webcam technology for face-to-face encounters when saying goodnight in bed. Their love affair takes them out of cyberspace for several in-person encounters. Emotions are high and limerence, that state of intense romantic desire for another person, is clearly evident. This is an affair of great proportions - emotional, cerebral and physical - filled with the excitement and consequences of infidelity. Another young adult, who is engaged to be married, logs into Second Life and soon he has created an “alter”; an 11 year-old girl who he describes is a part of himself. This story line is richly psychodynamic, offering a glimpse into the impact of virtual worlds on the lives of people who have experienced childhood trauma. The vulnerabilities of the adult male, his alter child female, his “real life” fiancée and other avatars the child befriends in Second Life are

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all laid out across the screen in a disturbing yet expected fashion. Thirdly, a woman searching for meaning in her vocation discovers that she can merge her love of gaming with her talent for design. She also explains that she has been dealing with several health issues so working from home is a plus for her. She starts a business creating a line of clothing and accessories as well as designer homes and landscapes. She manages to turn her hobby into a profitable enterprise. As with any entrepreneur, she applies focused concentration and long hours. Sadly, she has to fight lawsuits in the offline world when her designs are stolen and distributed freely throughout the Metaverse. Ultimately, she wins just $500 from the lawsuit. It is the stuff of life that therapists have been dealing with for years, or is it? The director describes his introduction to Second Life in 2006: I went into Second Life in the fall of 2006, when


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Life 2.0 Film Still: Avatars of lovers who met through Second Life

it started getting a ton of media attention. And it was great fun. At first I created a ridiculous avatar: he was really short and fat, and had a mowhawk, and wore short shorts and bare feet… But I soon found that no-one would talk to me. They just wanted to talk to all the sexy avatars. I tried changing my gender to a woman in a sexy outfit, and immediately people wanted to chat with me. I had a visceral physical reaction – Second Life was so immersive and disorientating…. This

felt like an important historical moment: the birth of something that could have a major impact on people and society. It was a no brainer that someone had to make a film about this. (BFI, 2010, p1)

Jason says he soon encountered the sort of problems that may seem easily anticipated on embarking on such a project. Obstacles included learning how to film in the virtual environment; conceptualising the film itself; and getting access to the makers of SL for comment (Linden Labs) – let alone

finding participants in an environment where privacy is closely guarded. The backlash to the film was swift in being accused as being unrepresentative of what actually happens when inworld and offline worlds collide, described well at the Second Thoughts blog at SecondThoughts.typepad. com. Much of the criticism apparently centred on the documentary displaying the “dark side” of virtual reality

environments, which many consider being a minority experience. Springarn-Koff’s own view is that SL can be a therapeutic outlet, but recognises that they can also be potentially harmful. He recognises caution in our use of them, stating “this is the time to help shape these worlds for the benefit of humanity. At its core, Second Life is about relationships and human interaction” (BFI, 2010, p2).

So what does this documentary offer those of us in the helping professions? How about a new chapter in multiculturalism? Cyberculture is rich, full, real and impactful. Our clients don’t just go to soccer games or movies or to Paris or Walt Disney. They don’t just have clandestine affairs at work or deal with historical issues of abuse in the therapist’s consultation room. They go to Second Life, another destination rendering the thrill of decadent and

Life 2.0 Film Still: Ayya Aabye and child avatars on a virtual beach

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clandestine meetings, corporate enterprise, vocational fulfilment and the ability to create a new beginning, reconstruct a past event, or extend parts of oneself into another reality. Life 2.0’s impact is growing. It has been bought by the Oprah Winfrey Network (OWN) cable

director). You can also follow Jason on Twitter @life2point0 for updates. We interviewed Jason in September at the Counselor Education in Second Life (CESL) 2010 conference, which will be available to view within the Institute’s forthcoming course in Cyberculture.

the world simultaneously from whatever geographical location they happen to be in at the time (O’Connell & Groom, 2010). Working therapeutically in virtual environments is well documented (Wilson, 2010; Riva, 2010; Tan, 2010). But even if your intention is not to use virtual realties in your services, the understanding of your clients’ experience of them is important. If you have the opportunity to view Life 2.0, don’t miss it. Your understanding of cyberspace will grow beyond measure. n

A Second Life user looks at his avatar

channel for the Documentary Club, an enterprise similar to the incredibly successful Book Club. It is due to air in 2011, when it will also be available on DVD an digital avenues (see NewWorldNotes blog at http://nwn.blogs. com/ for more information and for an interview with the


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Virtual worlds are more than just a place to hang out and form relationships, whether as diverse as those featured in the documentary, for business, or for fun – they are also a valuable teaching venue where interested professionals can gather from all over

Kate Anthony and DeeAnna Merz Nagel are co-founders of the Online Therapy Institute and managing editors of TILT ~ Therapeutic Innovations in Light of Technology

Photo Credits Film Stills Jason Spingarn-Koff Director’s Portrait Sabrina Gschwandtner

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Jason Spingarn-Koff is an American documentary filmmaker and journalist specializing in the intersection of science, technology, and society. His feature documentary "Life 2.0," about a group of people whose lives are dramatically transformed by the virtual world Second Life, premiered at the 2010 Sundance Film Festival and will be featured on OWN: The Oprah Winfrey Network’s documentary film club in 2011. He served as producer of NOVA's “The Great Robot Race,” the development producer for PBS’ Emmy-winning “Rx for Survival,” and the producer / director of the Student Emmy-winning “Robofly,” as well as documentaries for Frontline/World, MSNBC, and Time Magazine. He is a graduate of Brown University and the UC Berkeley Graduate School of Journalism, and is currently an MIT Knight Fellowship in Science Journalism for 2010-2011.

REFERENCES British Film Institute (2010). Programme Notes to Life 2.0. Filmographic Unit, BFI National Library O’Connell, J. and Groom, D. (2010). “Virtual Worlds, Learning in a Changing World”. Acer Press. Victoria. Riva, G. Using Virtual Reality Immersion Therapeutically. In Anthony, K., Nagel, D.M., and Goss, S. “The Use of Technology in Mental Health [applications, ethics and practice]”. CCThomas, Illinois. Tan, L. The Use of Virtual Reality for Peer Support. In Anthony, K., Nagel, D.M., and Goss, S. “The Use of Technology in Mental Health [applications, ethics and practice]”. CCThomas, Illinois. Wilson, J. Using Virtual Reality to Conduct a Therapeutic Relationship. In Anthony, K., Nagel, D.M., and Goss, S. “The Use of Technology in Mental Health [applications, ethics and practice]”. CCThomas, Illinois.

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Jean-Anne Sutherland


n July of 1999, Entertainment Weekly (EW) made mention of Hollywood’s preoccupation with therapists in several recent films. When asked about the depiction of therapists in film, Dr. Steven Hyler (Clinical Professor of Psychiatry, Columbia University) responded, ''I'm not really worried about the way we're portrayed. We like a good movie just like anyone else.'' There are two ways to respond to Hyler’s statement. The first is to agree: movies are fun and, as an old friend of mine used to joke, “Why ruin a good story for want of a few accurate facts?” On the other hand, media images (in this case, film) are one ingredient that contributes to our social constructions. Research has shown a correlation between watching evening news and racial attitudes. Research has explored the relationships among media images, young women and body perceptions and found that, yes; these images wield the power to impact girls’ experience of their own bodies. Not that researchers assert a causal relationship between media images and behavior (that is, one does not view imagery and then, zombielike, walk out an exact imitation). But current media studies tend to agree that we are influenced in more active ways, as we watch movies and engage with them. What does this mean for the average person coming to therapy for the first time, yet knowing little of it except for what has been experienced in the dark of our theaters? As EW noted in 1999, the film industry continues its love affair with therapy, therapists and mental illness. Films depicting therapy in action range from the absurd (What About Bob; Analyze This) to the touching (Ordinary People). Therapists or psychiatrists in film are represented as widely divergent, as well. Michael

Caine in Dressed to Kill comes across as the uberappropriate and smart therapist, until the end of the film when we discover that he, in fact, is the psychokiller. Bruce Willis in The Sixth Sense is the sensitive, present psychologist - until we discover he’s actually dead. And the premise of The Shrink Is In has the doc suffering a breakdown, after which—what else? - a patient steps in (because it is that easy). And lord help anyone who lands in a mental institution: One Flew Over the Cuckoo’s Nest; Girl Interrupted; Manic—these movies invariably depict professional dysfunction. It is the INSTITUTION that is crazy, not the patient. It is the medical profession’s devotion to rigid diagnosis codes that trap misunderstood people inside the walls of bureaucracy. Of course, not all images are incorrect, exaggerated or flatly derogatory. At least we can say that, in general, film today depicts mental illness with much greater balance and compassion than in the past. Films like As Good as it Gets and A Beautiful Mind tend to elicit great sympathy for characters suffering from mental illness. It is clearly stressed how often such illnesses are misdiagnosed and misunderstood. Perhaps, then, current cinema has played some valuable role in removing some of the stigma once associated with seeing a therapist. And this is a positive thing, even if those clients do enter therapy with their heads a brim with Hollywood’s interpretation of therapy sessions, therapists—the social construction of mental illness. Jean-Anne Sutherland, Ph.D. is assistant professor of sociology at University of North Carolina Wilmington, USA with one of her research focuses being sociology through film.

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Jason S. Z ack

Does HIPAA Require that Communications with Clients/Patients be Encrypted? HIPAA (the Health Information Portability and Accountability Act) is the U.S. Government's statutory scheme for protecting the electronically-stored private consumer health information that is shuttled back and forth routinely among health care providers and health plans. In 1996, Congress endeavored to ensure that such data was not compromised and developed a set of rules, administered by the U.S. department of Health and Human Services (HHS), limiting the way electronic health information may be stored, accessed, and transmitted. Violating HIPAA rules can result in stiff penalties. As online mental health professionals deal with electronic private health information on a regular basis, many are concerned about whether HIPAA applies to them. It's important to understand what HIPAA does and does not require. Fortunately, HHS has a great deal of HIPAA-related information that is fairly easy to digest. For the purposes of this column, I focus on a single question frequently asked by online mental health counselors: “Does HIPAA require me to encrypt email communications with my clients?” The technical answer is “no,” because HIPAA does not mandate encryption. However, the more nuanced answer (there always is one where legal issues are involved) is that HIPAA does require mental health counselors (net-


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enabled or not) who conduct certain transactions related to health insurance to provide for the security of their clients’ personally identifiable electronic health information. Encrypting email communications is one way to do that. Thus, a more accurate answer is that encrypting client communications is one way for online counselors to meet one aspect of the HIPAA requirements, where applicable. On the other hand, providers who don’t conduct those certain transactions aren’t covered by HIPAA at all. Although beyond the scope of this column, it is important to note that if HIPAA is applicable, it will impact an online counselor's practice beyond simply requiring secure communications with clients. HIPAA’s security and privacy rules also address the manner in which your clients’ private health information should be stored on your computer and measures you should implement to prevent unauthorized access to your clients’ private health information.

*Does HIPAA Apply to Online Counselors?* The HIPAA privacy, security and administrative simplification rules apply to “covered entities.” The rules are aimed primarily at health plans and health care clearinghouses, but health care providers are included if they conduct certain health care transactions electronically. According to the HHS, health care providers, regardless of size, are covered entities if they transmit health information in connection with certain "standard" transactions, including: • health care claims • determination of health plan eligibility • referral certification & authorization • health care claim status • enrollment & disenrollment in a health plan • health care payment & remittance advice • health plan premium payments • coordination of benefits

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Counselors who don’t transmit their clients’ private health information to assess eligibility under a health plan are unaffected by the HIPAA regulations. See 68 Fed. Reg. 8372 (“Health care providers that do not conduct electronic transactions for which standards have been adopted are not affected by these regulations.”). For those who do use their client’s private health information for the transactions above, HIPAA's Privacy Rule will aim to protect all "individually identifiable health information held or transmitted by a covered entity . . . in any form or media, whether electronic, paper, or oral." This information, including demographic data, includes records of the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. The two primary general requirements under the HIPAA security rule are that covered entities must: • Ensure the confidentiality, integrity, and availability of all electronic protected health information the covered entity creates, receives, maintains, or transmits. • Protect against any reasonably anticipated threats or hazards to the security or integrity of such information. Covered entities “may use any security measures that allow the covered entity to reasonably and appropriately implement the standards and implementation specifications . . .” 45 C.F.R. § 164.306. In other words, using a program to encrypt emails would be one method, but other methods of protection are allowable.


The HHS makes it clear that simply "using electronic technology, such as email, does not mean a health care provider is a covered entity." Rather, "the transmission [of protected health information] must be in connection with a standard transaction." (HIPAA Privacy Rule Summary, p. 2).

Yale University, for example, has established certain guidelines for its healthcare professionals that require any patient-professional electronic communications to be transmitted using a "secure messaging service." This type of service does not encrypt the message. Rather it stores the message on a secure server for retrieval by the recipient upon notification that a new message is waiting for him or her. Yale’s protocol allows patient-provider communication by standard email, but only after the patient consents to the increased risk, and all emails must contain a privacy notice. Regardless of how clients’ private health information is used, online counselors are well advised to take certain precautions, especially if any of the information transmitted to clients may eventually be used in one of the HIPAA-covered transactions. Indeed, it is simply prudent to do what you can to safeguard your clients’ private health information--I’ve written elsewhere about legal reasons you would want to do that. And if you’re using secure email for clients that involve health insurance, you may as well use it for all of your clients. In sum, HIPAA requires that your clients' private health information be protected in some fashion if you transmit it for certain insurance-related purposes. It does not mandate encryption for all health-related communications regardless of the context. Still, if you

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engage in any kind of communications related to insurance or claims for your services, you should take a close look at the HIPAA regulations to ensure that you are in compliance. And of course, if you need legal guidance, seek the assistance of an attorney.

REFERENCES Summary of the HIPAA Privacy Rule, U.S. Dep't of Health & Human Services (2003), available at http:// summary/privacysummary.pdf (retrieved October 20, 2010) Guidance on the Use of Email Containing PHI, Yale University, available at guidance/emailconfidentiality.html (retrieved October 20, 2010) Health Insurance Reform: Security Standards; Final Rule, 68 Fed. Reg. 8334 (Feb. 20, 2003)

HELPFUL LINKS • HIPAA Frequently Asked Questions - http:// • Summary of the HIPAA Privacy Rule y/hipaa/ understanding/summary • Yale University's HIPAA Compliance Guidelines, available at

Jason S. Zack is a practicing attorney in New York, New York. He is a former behavioral science consultant and Past-President of the International Society for Mental Health Online (ISMHO). Disclaimer: Any opinions expressed herein are Jason’s own and not necessarily those of his employer. This article does not constitute legal advice and does not create an attorney-client relationship between the author and anyone reading it.


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Second Life A Virtual Playground for Therapists, Creativists, Healers, Educators, and Everyone Else BY Niela Miller (aka Marly Milena in SL)


n the fall of October 2007, I was sitting in a cafe with a friend and her partner at an annual event for transgenders called Fantasia Fair in Provincetown, Ma. I had been doing group and individual work at the fair for over twenty years at that point. They were telling me about Second Life, a virtual 3D location on the web. How ironic, since many would view this TG world as also being outside reality as they know it! In fact, these two had met

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in Second Life and have been partners there and in their regular lives for four years. As soon as I heard about Second Life, I got excited and curious since I saw its potential for creative projects of all kinds, for doing teaching and therapy in new ways, for meeting people from all over the world, for finding just about any interest group I could think of, and for having a lot of fun.

Prism Lila, an island inhabited by a dozen residents each of whom rents a parcel of land and can build on it. (There are thousands of such islands in SL and also a mainland.) Some of us are artists, some are teachers or therapists, some are builders and some are facilitators of programs such as Noetic Explorers, the virtual presence of the Institute of Noetic Science in SL: next door to my octagon called Octagon: Creative Exploration where I offer all sorts of programs using arts processes for personal growth and educational ventures, employing my skills in Gestalt and Jungian modalities.

My problem was that I was a serious technophobe, afraid of things going wrong on my computer, trouble with remembering how to use electronic devices like recorders, and, Here's how a session might in general, intimidated appear to you: by anything structural or mechanical with moving I am on a headset so my A group gathers---maybe parts. If this sounds like five, maybe twenty---I voice can be heard. I ask you, do not despair. A ask for a volunteer to do the volunteer to focus miracle occurred for me; a demo of a coaching my creative side trumped on a current challenge, process. My friend, Skov, my technophobia! I was a coach and NLP teacher feel what it evokes in the willing to learn what was from Denmark with body sitting at home at necessary to function in whom I collaborate in this Brave New World. My the computer, and then SL, sometimes hosts the friend offered to be my sessions on his virtual to build something which guide and mentor and I sim and sometimes it is symbolizes that feeling was off and running---well on mine on the beautiful not quite. It was actually state. glass-domed roof of my funny learning how to Octagon. walk all over again, how When the volunteer to fly (thrilling!), how to comes forward, I set up manipulate objects, how some guidelines such as confidentiality, willingness to dress my Avatar (the character one adopts along to share with group, sharing to be done in the chat with a new name), and hundreds of other pieces bar after the demo which restricts any analysis of the of technical know-how I needed to be a successful volunteer but, rather, focuses on what it brought up denizen of SL. I still feel I am learning each time I enter in the person who is sharing. I am on a headset so my SL. It has also changed my level of fear back home. voice can be heard. I ask the volunteer to focus on I now no longer panic when some equipment is not a current challenge, feel what it evokes in the body working correctly and can often find a solution, a new sitting at home at the computer, and then to build experience for me. something which symbolizes that feeling state. I have Jump to the present. I am in my third location in a building specialist present to help the person with Second Life, a sim (or simulated landmark) called minimal skills. It is not difficult, however, to simply pull 32

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a basic geometric shape out of a Create window, put it on the ground, stretch it, give it a color or texture.... Then I might do Gestalt work (it depends on what the situation calls for): they become the object, speak to the creator part of them and a dialogue ensues while, all the time, I ask them to pay attention to what is happening in the body at the computer. There is an immediacy and sense of control with being able to manipulate these objects in real time and change them as the person's perception shifts. Some remarkable insights and changes occur on the spot such as the woman who was in the middle of a panic attack when she volunteered and who reported that the anxiety dissolved after about ten minutes of work. She said this had never happened to her before with her other panic attacks, even when she was with a helper. I think that the ability to create and change the object as one goes along (to be inside or on top of it, make it smaller, larger, translucent, etc.) produces a set of conditions that helps the person feel in charge of creating change by shifting perception and perspective. I foresee a great use of virtual worlds, particularly Second Life, the most developed of these worlds so far, for healing, therapy, and teaching among others. Already, a lot of this type of activity is going on. My particular interest is in developing and using creative processes available in this technology combined with various models from humanistic psychology and adult education. I also use photographs, paintings, music, theatre improvisation and movement as tools for awareness, problem-solving, community building, spiritual development and building cultural bridges. I am eager to collaborate with other people and institutions who want to do this type of exploring.

want to formalize the payment structure more. If you want to have more of an introduction to SL than I can give here, please go to YouTube and search for Second Life videos. There are many. If you know you want to experience this world firsthand and see what might be possible for you to do there as a therapist, educator or group leader, go to and join. It takes five minutes and is free. Once you have an Avatar name, please email me at and I will do my best to help you acclimate. ABOUT THE AUTHOR Niela Miller aka Marly Milena has a business in Acton, Ma., USA called PeopleSystems Potential. She makes use of an extensive background in many arts, Gestalt and Jungian therapies, organization development and education/training. Her group in Second Life is OCTAGON:Creative Exploration where she designs and implements many programs, sometimes with collaborators. Her current main interest in both worlds is to train professionals in the use of creative tools to enhance their practices.

As for remuneration, there is a system of banking in SL involving a currency called Lindens (after the Linden group who are the builders and creators of SL). I don't depend on being paid in SL although people do leave Linden <tips> after each program. My focus is experimenting with what is possible, finding collaborators, and enjoying the process. Others may T I L T MAGAZ I N E nov e m b e r 2 0 1 0


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Online Mindfulness-based Therapy: Convenient, Effective and Affordable M

indfulness-based Online Therapy has gained tremendous popularity over the past few years. It provides the tools you need to manage depression, anxiety and emotional stress in the comfort of your own home and it is much more affordable. Mindfulness is becoming the preferred awareness tool for creating the right inner environment in which transformation and healing take place. The convenience of Online Mindfulness Therapy is one of the most cited reasons why more and more people are turning to this first. All you need is a laptop with a videoconferencing program installed and you are ready to start. Many people would like the opportunity of working on resolving their emotional problems, depression, anxiety, stress or past trauma but simply do not have the time to commute to and from a therapistâ&#x20AC;&#x2122;s office. Online Mindfulness Therapy allows me to work with clients from all over America, as well as helping clients in Europe, Australia, South Africa and beyond. We correspond through email to work out a convenient time and then connect through a videoconferencing program to begin a session. It is amazingly simple, and what is more amazing is that free video conferencing programs are available. Payment for sessions is also easy to make online through PayPal, which is very secure.

Besides the convenience, Online Therapy is typically much less intimidating than going to a therapistâ&#x20AC;&#x2122;s office and sitting in a waiting room. It is important that the client feels comfortable and in control, and Online Therapy, which some would say is in many ways a form of Life Coaching, is as natural as going to the local Recreation Center for a good workout. The client controls the whole process and this is empowering, which is important for the transformational process. Conducting a therapy/coaching session in the familiar environment of oneâ&#x20AC;&#x2122;s home or office is also more conducive and helps the client get in touch with his or her feelings, which is of course essential for good therapy. Most online sessions are a combination of counselling and therapy. As a mindfulness-based therapist, I alternate between being a teacher, coach and counsellor, providing advice and instruction on the application of mindfulness for resolving difficult emotions at the core level. That is one aspect of the work of online therapy. The other involves experiential work with the client, helping him or her get in touch with core emotions to facilitate their resolution through mindfulness-based techniques. This approach works particularly well in video sessions because clients feel

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so much more at ease in the comfort of their own home. Another characteristic of online therapy is that clients are invited to email me in-between sessions if they have any questions about the homework assignments they have been given. In this way the therapeutic process has continuity, which can be lacking in more traditional approaches, and the client feels that they have a friend and coach to turn to when the need arises. Feeling comfortable with the therapist/coach/teacher is essential and in my Online Mindfulness Therapy sessions, I take great efforts to answer my clientâ&#x20AC;&#x2122;s questions either during a session or through email. It is my policy that each session should bring some tangible improvement for the client and that he or she should feel good about each session. That after all is the key factor that you should use to decide if any therapist, online or in-person, is right for you. What matters is that you feel that you have benefited from each individual session. Most clients who come to me notice significant improvements within 4-5 sessions, not 4-5 years as in some forms of conventional talking therapy. Online Therapy is becoming more widely accepted as a valuable adjunct to traditional in-person psychotherapy and there have been several controlled studies that support its efficacy (Barak et al., 2008). The focus of online therapy/coaching is on teaching clients the skills and tools that help them break free from the grip of depression and anxiety or other difficult emotions, and we can all benefit from that. It may not be the first choice for those with a clinical condition, but most of us do not have a mental disease; we just need someone to talk to who understands and can teach some practical tools for handling the stresses of life and the emotional challenges inherent in a marriage or other personal relationship. In fact, the demand for good quality counseling and therapy, including the very popular mindfulness-based psychotherapy, far


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outstrips the availability of quality providers, which is yet another reason why you should seriously consider online counseling as an option. Finally there is the issue of cost. Generally, due to lower overheads, online therapy is considerably less expensive than traditional therapy sessions. Typically, sessions cost somewhere between $70-$120 / hour, which is very good value. The only down side is that few insurance companies will cover online therapy, as it is still relatively new and the Establishment takes time to embrace innovations. Most online counselors will demand pre-payment for a session, but I prefer to accept payment after a session. That way, no charge is incurred if a client feels that the service is not right for them. Itâ&#x20AC;&#x2122;s another good way of getting to that all-important comfort level where the client feels that this is indeed the right choice for them, which it is for the growing number of people

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who want to learn better skills for managing their emotions through online coaching sessions. I practice both in-office and online and find both approaches to be equally effective, and there are a growing number of therapists who feel the same way and offer both options. Of course, phone counseling has been around for many years, but video sessions have revolutionized the service, and unlike the telephone, some Voice over Internet Protocol (VoIP) call programs are available at no cost. n ABOUT THE AUTHOR Peter Strong, PhD is a scientist and Buddhist Psychotherapist, based in Boulder, Colorado, who specializes in the study of mindfulness and its application in Mindfulness Psychotherapy for healing the root causes of anxiety, depression and traumatic stress. He is the author of â&#x20AC;&#x2DC;The Path of Mindfulness Meditationâ&#x20AC;&#x2122; (2010, Outskirts Press). Besides face-to-face therapy sessions, Dr Strong offers Online Mindfulness Meditation Therapy through Skype at Reference

Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a metaanalysis of the effectiveness of Internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26, 109-160

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an Online Therapist

A Day in the Life of

I am semi-retired. I had to take early retirement from teaching, due to ill health (ME), in 1993. Fortunately, I was already studying for a Certificate in Counselling and this was to be my transition to a new career. I now practice as a face-to-face counsellor both for an agency and privately and have very recently begun an online practise.



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I’m venturing into cyberspace at a gentle pace. I’m a member of a variety of online forums and contact lists but I tend to be a reader rather than a contributor to them. My web page ( has just been launched so I am looking forward to putting my training in online therapy into practice. My website appears in several directories and it has been featured by both the Online Therapy Institute and Freeola (my ISP). I am anxiously awaiting enquiries. My face-to-face counselling work takes up two days a week. On the other days I sit at my computer working or browsing, I am beginning the process of organising a college reunion and I play golf. The latter ensures that I get some exercise outdoors and is a great way to meet others in an informal and relaxed atmosphere – a wonderful antidote to counselling. I get up at about 6.30. I check my emails on the PC - mainly in the hope that I have a new online client. There are none this morning but I catch up on a couple of discussion threads on ISMHO. I’ve been following the one concerning the use of Skype. I listen to the news while eating breakfast then leave the house at 7.45 am. I work for an agency which offers face-toface counselling to employees of a branch of a national organisation. I arrive at about 8.30 allowing time to relax a little before my first

appointment. I switch on my laptop so that I can do any admin, write or draft responses to emails in any appropriate gaps in the day. At 8.50 I read through notes for my first client at 9.00. The majority of issues relate to bullying. I take advantage of the cancellation of an appointment and go to the staff snack bar for a cup of coffee and relieve the sense of isolation I have working in this situation. I do find that by being amidst a number of other people for a quarter of an hour or so, together with the short walk there and back, refreshing. It is also a chance to catch up on reading an article in a journal. Lunch, which comprises a sandwich, some fruit and a cup of coffee from a vacuum flask, is taken in the gap between appointments at 1.45 and 2.00. My last appointment ends at 5.30. There are no potential email clients awaiting me, causing me to consider what more I need to do to attract them. I think a more careful look at the videos of Laura Dessauer and Dr Susan Giurleo would be time well spent this evening. About the author Geoff Cox is an online therapist in private practice and lives in the West Midlands, UK.

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Cyber Supervision Anne Stokes

In the UK, clinical supervision is a lifelong professional requirement while we are in practice, not an option (which may be the case in some countries). This has given rise to a debate, at times heated, about whether online supervision is ethical and/or equivalent to face-to-face supervision.

this client. Extracts of client emails can be sent to the supervisor, although ethical concerns about this are considered later. Like clients, some online supervisees may feel able to be more open about their work than they would be face-to-face, and tricky issues explored more easily.

For the purposes of this article, online supervision refers to textbased supervision, rather than to voice and videoconferencing supervision. Although there are some similar issues, the latter have more in common with telephone or face-to-face supervision than purely text-based work.

Then there are the contextual and professional reasons, for example the ability to access supervision from a specialist who is not within travelling distance. Our faceto-face supervisor may have no knowledge or experience of online work, and therefore not be able to, nor wish to, supervise this part of our work.

What Are the Benefits? The most obvious benefit is that it parallels the medium we are working in. It is possible to ‘hear’ the supervisee’s online voice and to notice any changes. This may lead us to be curious about what might be happening that is different with


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Finally, there are reasons that are more pragmatic. With email supervision, there is a flexibility within given time boundaries to write (though not necessarily send) when it is most useful or convenient. So, for example, if I have a specific issue I want to take

to supervision, I can write that part of the email while it is ‘hot’ or at the forefront of my mind, rather than having to wait to recall it. It is the same with responses; I can jot down thoughts in response as they occur to me, and I don’t have to think on my feet in the same way as when I am supervising faceto-face. Even if I am conducting synchronous supervision, I will often have had an agenda from my supervisee, or an extract to read before the session. We don’t have to travel to online supervision, which saves time and travel costs. It may be easier to fit in an emergency supervision email, since we don’t have to arrange to be in the same place or at the end of a phone at the same time. So How Might It Be a Cop-out, Or Unethical? A huge concern for many practitioners is around safety and confidentiality. In practice

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Online Supervision– Ethical or a Cop-Out? if both parties follow the same requirement for ethical online practice with clients, such as using encryption, then to some extent this concern can be alleviated. However, it may be more difficult to anonymise a client. Obviously extracts sent to a supervisor should be blinded, with all personal information such as names and email address removed.

with issues such as this should they arise? There aren’t necessarily right or wrong answers, so each contract may be different – a future article here!

There is still the possibility of a client being ‘recognised’ by a supervisor, since more people and detail within the client’s narrative may be evident in an extract, than in a face-to-face account. We can argue that usually the supervisor and the supervisee are not living in the same areas, so it is very unlikely that this will happen, but to ignore the possibility is unethical.

Generally, online supervisors and supervisees are more rigorous about contracts, in my opinion, simply because they have to write to each other about what will go in to it rather than simply talk. Having said that, I can think of one example from my own practice where this isn’t so, and that is where I changed to online supervision from face-to-face with a supervisee. I suspect that I haven’t re-contracted sufficiently clearly for this new medium. That’s one of the spin offs of writing articles – you shine a spotlight on your own practice too!

This brings me to what is perhaps the most vital element of ethical online supervision – a clear contract. What are the boundaries in general, and how will we deal

Face-to-face practitioners have said to me that they think online supervision is a cop-out because you can quickly whizz off an email, and that’s it. Or you can

answer other emails, or make your shopping list during a synchronous session while waiting for the other person to type a response. Of course, that could happen! However, in general terms, most online practitioners tell me that they take more time in writing a supervision email than they take in preparing for their faceto-face supervision session. The amount of energy needed to stay focused in a real time session may be greater than in a face-to-face session. In my experience, online practitioners are aware of this, and do expend that extra energy to remain focused. Another possible ‘cop-out’ may be that online supervision is very hard to equate to face-to-face supervision in terms of time. If your professional body requires you to undertake a certain amount of supervision per month, how on earth do you equate that with online work? Again, face-to-face

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practitioners often argue that an hour spent online is not the same as an hour face-to-face as most people talk faster than they type. This is true. However, do we really want quantity rather than quality? I could make other arguments about how e-supervision often gets to the heart of things quicker than faceto-face, and how we don’t exclude silences in face-to-face sessions when talking about calculating hours. To do that would seem to be getting into an argument about which is ‘better’ and for me that is an irrelevant discussion. They are equally good and useful (or not!) but are different. A very valid fear around supervision of online work concerns the supervisor who has not trained in online work. This is most likely to happen where supervisees take their online work to a face-toface supervisor. This does feel as if it could potentially verge on the unethical. How can someone who has not experienced working with online clients really offer the best possible supervision? It amazes me when sometimes I hear counsellors say that it is OK to take online work to face-to-face supervision, but not the other way round. If it is wrong one way, it must be wrong the other. Or neither is wrong. The Way Forward? I am rapidly concluding that online supervisors need to be online


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practitioners themselves, and trained in online supervision. For many years, face-to-face supervisors were not trained, but evolved because they were experienced and respected practitioners. The profession then decided that however good they might be, training could make them better. Online work does not need to take so long to get to the same place, but we can learn from the history of our profession. We must have robust contracts in place that address areas where online supervision could be perceived as a cop-out or unethical. Those of us who have been supervisors since the early days of online work need to go back and examine our contracts to see if they do stand up to scrutiny. Perhaps as a final thought on the

way forward, a recommendation might be that all online practitioners should undertake annual CPD around online therapy, or through online workshops. That would have a spin off, I suspect, in avoiding some of the issues that arise in online supervision. AUTHOR’S NOTE This article arose from my reflections after a workshop I facilitated at this year’s OCTIA (Online Counselling and Therapy in Action) conference and I acknowledge the contribution of the participants to my current thinking. As with so many areas of online work, we are still searching for ‘best practice’ and so I’d love to hear the views of other practitioners.

Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer, and Director of Online Training Ltd.

TILT – Therapeutic Innovations in Light of Technology

Ne wInnovations 1

Three Ways to Use Social Media in Your Practice Mark Goldenson I was at a health care conference when a panelist asked the audience a question. How many people use Facebook or Twitter? Only about a quarter of hands went up. How many people want to learn Facebook or Twitter? Almost three-quarters of hands went up. The room broke into laughter. Health professions tend to be late adopters of technology, but social media sites like Facebook, Twitter, LinkedIn, and Youtube, which started mainly for individuals, are becoming indispensible tools for businesses. Here are three ways to use them for your practice:


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Businesses often use social media to gain exposure and reach new customers. With Facebook, Yelp, and LinkedIn, you can build a free page with information on your practice like specialties, rates, and hours. With Twitter, you can send lightweight, 140-character messages – opinions, news items, marketing offers – that can be read and resent by others. With Youtube, you can upload videos to convey a richer sense of who you are. Good promotion is specific. Rather than use generic language like “I can help you improve the quality of your life”, highlight unique specialties or credentials, such as “I am the only therapist in Florida that treats phobias in Second Life.”



Social media lets anyone become an authority in a subject, and your therapist training enables you to educate people looking for answers to important questions. With Twitter, you can pose and answer questions (following up privately when appropriate). With Youtube, you can give longer answers or record lectures. With, you can hold live seminars, and with Udemy, you can build your own free or paid online courses. You can also build your own website or blog with free services like Blogger, Wordpress, and Wix. All of this can build your authority, which over time, increases your

visibility and the chance that clients find you. Your posts can also be found by search engines like Google. Pew Research reports 61% of American adults – about 150 million people - search the internet for health information, and over half were consuming user-generated sources. As one search engine optimization expert told me, every post is a lottery ticket that can be found in a search, and you can make as many lottery tickets as you like! Of course, this also means you should be careful what you post.



I think the most exciting aspect of social media is the ability to connect with people – for therapists, this means peers, press, and with appropriate measures, potential clients. LinkedIn lets you build your professional network and display recommendations. Twitter and blogs let you collect followers and engage in public conversations. You can even build your social network with Ning. One issue is whether and how much to communicate with potential and existing clients. I believe it is okay to communicate with people who may become clients as long as you disclaim that they should never reveal personal health information, and once you form a therapeutic relationship, that you only communicate via secure channels. On Facebook, a network oriented toward personal

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relationships, I recommend against friending clients and overstepping professional bounds. If you aren’t yet using social media, now is a great time to start, if only because too few therapists have. It’s not too late - you can still be an early adopter!

Mark Goldenson is CEO of, a free virtual office for online counseling.

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Marketing Toolbox Susan Giurleo

Where Are Your Clients and What do They Need? When you begin to market a clinical practice online, it’s exciting to imagine that you can potentially reach hundreds, if not thousands, of people with your services, products and programs. Unfortunately, the online world is huge and we need to target our marketing to the people who need and want our services if we hope to attract any clients. In my last article for the Marketing Toolbox I said I’d discuss simple ways to engage in online market research so you can find your clients, discover what support they need and introduce yourself and your service offerings. Let’s look at 3 places you can go online to find out where your potential clients “hang out” and what they need. 46

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Three Places to Find Out About Potential Clients and Their Needs: 1. BLOGS There are a large number of blogs dedicated to mental health issues. One of the largest is which includes many smaller blogs on many mental health issues. Most of these blogs are written by “experts” but where the market research lies is in the comments from mental health care consumers. Read what they have to say about their experience with a certain issue, how they feel about the treatment they receive and what they hope they could get from a provider in the future. You will start to see themes in these comments and when you do, start to brainstorm ways you can meet the needs that the consumers are missing. Those “holes” in the marketplace are where a business grows. Another place to look for mental health oriented blogs is AllTop bills itself as the “magazine rack” for blogs. You can type in any search term from ADHD to Major Depression and see what blogs are out there on these topics. For me, the best blogs for market research are those written by people who are living with a condition, rather than those of us who are “experts.” We want to know what people experience and need so we can help them. Listen in on their blogs. 2. SOCIAL MEDIA There are large communities of people in the social media space who gather to talk about their mental health conditions. You can use http://search. and type in any term (i.e. autism, depression, ptsd) and see what people are talking about on Twitter in real time. This is an amazing resource because you get to hear from people in their own words about what they are thinking and feeling at that very moment about their condition. Again, tune in for things people wish they could learn, experience or gain from their interaction with a psychotherapist. Look for themes and “missing pieces” that consumers are looking for. You can also start to follow people who tweet about your specialty area so you can see what they have to say on a regular basis. Similarly, you can use Facebook to find group pages related to certain mental health issues and conditions. Most of these groups you can “like” and join in the conversation. Personally, I like to read what people are talking about and, again, see what they want and need. If I can offer support or a resource, I may chime in, but I mostly observe to do my market research. An example of a large Facebook group is “Autism Awareness” which has over 246,000 members. Talk about a great place to get to know your market!

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TILT – Therapeutic Innovations in Light of Technology

Online Marketing Start-Up Kit continued 3. SUPPORT FORUMS There are a growing number of patient driven support forums on the internet. These include: and Both communities allow people to join a group that focuses on discussing resources and offers support for those suffering with a specific health issue. You can join a group and follow their discussions.

It’s important to keep in mind that your participation in all of these internet “hang outs” for clients should be low key and subtle. You are not there to promote yourself or your services. You are there to listen and learn. You will soon discover what your target clients need and where the appropriate places are to share your expertise and services. Remember the first step to marketing is understanding your potential clients and building trust with them. By listening on blogs, social media and support forums you will be well informed of exactly what your clients want and need. When you offer what people ask for or fill a hole in the marketplace, you will always have a full practice. Susan Giurleo, Ph.D. manages www.bizsavvytherapist. com, bringing mental health support to people via social media and online technologies. She is based in Massachusetts, USA


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Life-transforming ideas have always come to me through books. ~Bell Hooks O Magazine, December 2003

Love For the

Books of


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Cinematic Sociology: Social Life in Film Jean-Anne Sutherland and Kathryn M. Feltey, 2009, Pine Forge Press This one-of-a-kind text takes readers beyond watching movies; it helps them “see” films sociologically and develops critical thinking and analytical skills that will be useful in college coursework and beyond. Cinematic Sociology's 15 essays from expert scholars in sociology and cultural studies explore the ways social life is presented-distorted, magnified, or politicized- in popular film. Exploring a variety of captivating classic and current films such as Forty Year Old Virgin, The Devil Wears Prada, North Country, and My Fair Lady, this unique book helps students to view films sociologically while also providing much needed pedagogy for teaching sociology through film. Key Features • Enhances students' understanding of sociological concepts. Each essay uses one or more feature films to illustrate key central topics in sociology: social class, race and ethnicity, gender and sexuality, work and family, global connections, and social change and the environment. • Offers a framework for teaching sociology using film. This anthology provides instructors with an innovative and engaging method for teaching sociology; students are taught to see film as a type of "text" that can be analyzed and critiqued. • Teaches students to identify sociological concepts in film. Traditional sociological concepts such as identity, interaction, inequality, and social institutions are analyzed in the context of feature films. • Offers a comprehensive film index. The lengthy film index at the back of the book provides instructors and students with a resource for selecting films for critique and analysis.

Marketing for the Mental Health Professional: An Innovative Guide for Practitioners David P. Diana , 2010, Wiley A hands-on guide to building a successful mental health practice. There is real opportunity for growth, advancement, and overall success within the mental health profession. Marketing for the Mental Health Professional helps you acquire and apply the powerful, proven sales and marketing techniques and strategies needed to create and cultivate a thriving mental health practice. Filled with real-life stories and helpful tips, this book provides you with the tools to build your practice, including guidance on: • Using customer-based selling to create a thriving practice • Developing effective strategies for engaging clients, building credibility, and earning loyalty • Identifying true prospects that will lead to long-term success • Using power, influence, and persuasion to help grow your practice • Creating an impression and being remembered • Using Internet technology to start a conversation and build relevance A practical guide for professionals looking to achieve long-term success in the field, Marketing for the Mental Health Professional proposes a different way of thinking about the profession. It leverages and incorporates key business, sales, and marketing principles that "best in class" organizations and sales/marketing professionals use to generate an increase in market share, financial wealth, and overall achievement.

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In our JANUARY issue... 99 Paul Silverman writes on coping with and navigating conflicts by email 99 Deborah Owens describes her experience at the 2010 Counselor Education in Second Life (CESL) conference, as a newbie to virtual environments 99 Bob Acton discusses the Computerised Cognitive Behavioral Therapy (CCBT) package Beating the Blues 99 A Day in the Life of an Online Therapist: Ralph Friesen from Nelson, BC 99 And also much more, including… member’s responses to this month’s Ethical Dilemma, a new cartoon from Wounded Genius, and find out who is newly Verified by the Online Therapy Institute!

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