TILT Magazine Premier Issue

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Premier Issue September 2010

Alice In VirtualLand Healing the Inner Child through Virtual Reality PAGE 16

The Writing Cure Therapeutic Effectiveness via the Internet PAGE 9

Opening Therapeutic Doors to the iGeneration What the Helping Professions Need to Know PAGE 33 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 www.onlinetherapymagazine.com. ISSN 2156-5619 Volume 1, Issue 1, September 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 www.onlinetherapymagazine.com Writer’s Guidelines If you have information or an idea for one of our regular columns, please email editor@onlinetherapymagazine.com 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 www.onlinetherapymagazine.com.

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.

TILT MAGAZINE September 2010

Features 9 The Writing Cure Therapeutic Effectiveness via the Internet

16 Alice In VirtualLand Healing the Inner Child through Virtual Reality

33 Opening Therapeutic

Doors to the iGeneration What the Helping Professions Need to Know

Issue in every


News from the CyberStreet

12 Research Review

14 What Would You Do?!

15 Wounded Genius

29 Reel Culture

30 Legal Briefs

37 A Day in the Life

40 CyberSupervision

42 Marketing Toolbox

46 New Innovations

49 Look Who’s Verified!

50 For the Love of Books 52 Advertiser’s CyberMarket

A Note From the Managing Editors… A huge welcome from us as we launch the very first issue of TILT – Therapeutic Innovations in Light of Technology. It’s been a whirlwind to get together – from its inception while we were working together on a rarish visit (for Kate) to the USA in July, to getting it uploaded and ready to deliver to you. We hope you enjoy it as much as we have enjoyed putting it together. It is our aim, 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. We also take great pleasure in introducing our regular columnists and contributors: Stephen Goss, our Associate Editor for Research, is Principal Lecturer at the Metanoia Institute, and also an Independent Consultant in counselling, psychotherapy, research and therapeutic technology based in Scotland, UK. He will be providing you with research of interest that is currently taking place and information on online research methods. Jason Zack is a lawyer based in New York City, USA, and will be contributing commentary on legal issues that we frequently get asked at the Institute. He is also a Past President of the International Society for Mental Health Online (www.ismho.org). Mark Goldenson is the CEO of Breakthrough.com, a free online counseling practice for mental health providers. Based in California, USA, he will be contributing a column on new innovations in the field. Susan Giurleo manages www.bizsavvytherapist.com, bringing mental health support to people via social media and online technologies. She is based in Massachusetts, USA, and will be sharing with us her top tips for a successful practice as Associate Editor for Marketing. Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer, and Director of Online Training Ltd. She will be editing the column on Online Supervision as our Associate Editor for Supervision. Jean-Anne Sutherland is assistant professor of sociology at University of North Carolina Wilmington, USA with one of her research focuses being sociology through film. She will be sharing with us her thoughts on media that may not occur to us as being potential therapeutic tools within our work, such as film and TV. We are also pleased to offer you our first feature article, “Alice in VirtualLand”, written by us – a story of virtual reality and its effects on the therapeutic relationship. We take you through the tale of Alice and Lucy, and how Virtual Reality can be a tool for healing when in distress, and also one of education for therapists unfamiliar with such environments if open to being led by the client. Other articles are from Cathryn Heyman and Cedric Speyer, writing on Therapeutic Effectiveness via the Internet, Opening Therapeutic Doors to the iGeneration by Marina London and A Day in the Life of Audrey Jung, an online therapist and current President of the International Society for Mental Health Online (ISMHO). We hope you enjoy our first issue. All feedback is heartily welcomed at the OTI social network!

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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 www.onlinetherapysocialnetwork.com!


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Blog news… Here is a glimpse of what is going on…get a taster and then head to http://www.onlinetherapyinstituteblog.com/ and the blogs at www.onlinetherapysocialnetwork.com for more! Kate and DeeAnna recently saw Race on Broadway, starring Eddie Izzard and written by David Mamet. Kate writes on the themes of racism, sexism and online therapy that were stirred up for her as a result over at the main OTI blog. She ponders on how we ensure that our internal assumptions and biases around cultures and races (born of upbringing and social environment) do not infect the therapeutic work, either by self-reflection or in Supervision, in light of not necessarily knowing that level of detail about the client. Also at the main OTI blog, DeeAnna writes about Life 2.0, having caught the premiere in NYC. Life 2.0 is a documentary about relationships in Second Life, and we are inviting the director and participants to join us at the upcoming Counselor Education in Second Life (CESL) virtual conference held on the 15th to the 18th of September. Watch the OTI Calendar for more details! Kate caught it at the British Film Institute in London on 6th August, and agrees that watching it means that “your understanding of Cyberspace will grow beyond measure”. Issues of cultural diversity are no longer confined to geographical location… Over at the social network, John Wilson of the UK blogs about the changes that are happening at the Person-Centred Education and Training organisation http://www.temenos.ac.uk/ and the recent online interview with Buck Black of www.truckertherapy.com; Alisa Clark blogs about the power of True Story Memoirs and Spiritual journalling; and Laura Dessauer blogs useful information on running a therapy business.

Member news… The University of Birmingham Counselling and Guidance service recently launched Qchat – an online moderated chat room for sexual minority students. Visit www.as.bham.ac.uk/qchat . TinyEye have recently launched a free version of their online therapy games software that any Speech Language Pathologist can sign up for and use for free forever. Go to www.TinyEYE.com and click on the free games link. They have also released a new video profiling the people behind online speech therapy. Visit http:// www.youtube.com/user/MyTinyEYE#p/u/0/7X3hklvvXIk to view. The 1st Annual International Creative Art Therapies Teleconference took place during the week of August 23-27, 2010, and you can now access the replays of the 10

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TILT – Therapeutic Innovations in Light of Technology

expert speakers for this special international event. You can learn from luminaries in the field of art therapies and expressive arts, new techniques and tools to revitalize your practice and bring new knowledge and energy to your clinical work. Visit www.icatconference. com. The Council on Alcohol and Drugs are presenting a “Crash Course in Social Media for Mental Health Professionals", on December 3, 2010, 8:30 am - 4:30 pm, in Houston, Texas. For more information, visit http://www.eapassn.org/files/public/Houston1210. pdf Thomas Edison State College announces their Online Career Coach Facilitator Course. You can become certified as a Career Facilitator by registering for the online Workforce Career Coach Facilitator course, and satisfy the training requirement for the Global Career Development Facilitator Credential (GCDF). The GCDF is conferred by CCE, a division of the National Board for Certified Counselors (NBCC), the largest counselor certifying organization in the world. Visit www.tesc.edu/5011.php or call 609-777 5642 ext. 2217 for more information.


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Recruitment… Online Counsellor, Counselling and Guidance, The University of Birmingham This post, based in the Counselling and Guidance Service which is part of the Division of Student Support & Development, carries responsibility for delivery of individual counselling, group counselling and assessments. The service is looking to expand its group work programme and specifically, to develop its online counselling provision (synchronous, asynchronous and chat forums). We are looking for someone with a minimum 5 years post qualifying counselling experience, preferably in higher education. You should be BACP/UKCP or BPS accredited, have a qualification in online counselling and be experienced in the development and delivery of online counselling. You should also have proven experience in group work. Informal enquiries are welcome. Please contact: Jean Turner, Director of Service – 0121 414 5130.

Writing Cure The

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Therapeutic Effectiveness via the Internet Cathryn Heyman and Cedric Speyer

It is estimated that less than half of what we say is communicated through words, while the rest is spoken through nonverbal signals including tone, pace, inflection, body posture, facial expression, and eye contact. Since we often struggle to put our feelings into words, the majority of emotional information is communicated nonverbally. It is no wonder that many people are still sceptical when it comes to internet-based counseling. However, increasing client demand and evidence-based results point towards more use of one of the greatest mental health tools available to our mobile and widespread community – eCounseling. eCounseling goes by many names (distance counseling, cybercounseling, eTherapy), all of which refer to confidential communication between a counselor and a client over a secure internet connection in text-based format (including secure forms of email) or audio-visual (video chat). To ensure confidentiality, email or chat programs like Microsoft Outlook or AOL Instant Messenger are not used because the content of the 'conversation' can be intercepted by an internet service provider or anyone savvy enough to hack into the system. Instead, a secure webboard is used where to enter you must use a login name/password. Shepell-fgi has such a system in place. Once logged into the Shepell-fgi webboard, the correspondence takes place behind a firewall. To the person accessing services, it’s just a convenient string of exchanges in a private conference area. Throughout the remainder of this article, eCounseling refers to this text-based format.

Fact vs Fiction "How do you know the person writing to you is telling the truth?" You don’t know. The same can be said for in-person counseling. Counselors have to work with what the client brings to the session. While it is in the client’s best interest to be transparent, this isn’t always what happens inperson. In fact, most people have 'stories they tell themselves' until they feel strong or safe enough to embrace the therapeutic 'truth' of their life situation. In all forms of counselling, the goal is not to judge the teller or the tale, but to help the person 'live in a bigger story', one that gives them more perspective and freedom of choice. To this end, the 'writing cure' is

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TILT – Therapeutic Innovations in Light of Technology

an alternative to the 'talking cure' originally introduced by Freud. With the advent of email, we have come full circle back to Freud's practice of not having any face-toface contact with the client during therapeutic sessions or exchanges. It can free the psyche for a pure and deep form of dialogue.

Writing vs Speaking People who do not like to write or are not able to express themselves easily in writing are not usually drawn to text-based counseling, but a lack of writing ability does not prevent a person from benefiting from eCounseling services. There are times when a person starts eCounseling and after the first exchange, discovers that the dialogue can go much deeper when they're not 'on the spot'. What might be lost from the immediate give-and-take of natural conversation is gained from slowing the process down so the clients have all the advantages of keeping a journal of their thoughts and feelings while still part of a healing interchange.

Crisis Situations People who are in crisis are not candidates for eCounseling. The communication that takes place between counselor and client over the internet is asynchronous, i.e. there is a delay between responses. That means providing immediate attention for high risk situations is taken offline and handled through the S•fgi call centre.


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Clinical Containment "The eyes are the windows of the soul." (Shakespeare) Eye contact can be intimidating as well as comforting. When people are feeling vulnerable, they are less likely to speak their whole truth (reveal their core issue). Some self-disclosure can be withheld because it's felt to be too personal or even shameful to reveal to another person. Yet those deeply private parts of one's emotional life often hold the key to healing. The 'disinhibiting effect' refers to the feature of eCounseling that enables people to quickly reach the heart of the matter and get 'unstuck' without feeling so vulnerable. With the counselor not physically present, clients feel free to openly express themselves. There is no judging by appearances or visible personality traits. A reply arrives, but it is read in the client’s own frame of reference when she or he feels ready to receive it – after the kids are put to bed and the dishes are done, for instance,

no matter what the location or time zone.

Availability and Pacing An extra layer of comfort comes from the client’s ability to 'talk' with the counselor whenever the time is right. And if the client thinks of something else after having sent a reply, she or he can always write an addendum and send that along. It’s safe for clients to be in control of the send button and gauge the level of their self-disclosure accordingly. The client replies to the counselor at their own pace and rate; thus, a built-in sense of containment is established. The counselor is required to respond to the client within two business days. In this way, the rhythm is set by the client, not dictated by the clinician who may only have one evening appointment available every third week, for example.

Writing Heals Research has shown that the act of putting thoughts and feelings into written words is healing in itself.

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(James Pennebaker (2007) at the University of Texas describes this well) Writing allows the author to witness the experience from a safe distance, making it possible to form a new perspective. Once it's 'seen in print', the author has a tangible record of the thought or feeling. When a life predicament is externalized in this way, it becomes less threatening and easier to manage. Writing it down gives the client a sense of authorship, first for how the story is told, then for what it means and finally with the counsellor's feedback, for how it will then unfold in the next life episodes. Keeping a journal in order to grow in self-awareness has always been a time-honored practice. Now eCounseling offers a journal that answers back, containing the reflections and guidance of a trained professional. The urge to talk with someone about a problem is really an urge to access one's inner guidance. There’s a need to straighten out something that has you feeling tangled on the inside. The counselor’s role is to facilitate a conversation addressing the tension between 'the inside story' and the persona that functions in the outside world. When inside/outside aspects are aligned, they form a unified whole and feelings of security grow. You may want to visit Dr. James Pennebaker’s website and experiment with the Writing and Health exercise: http://homepage.psy.utexas.edu/ homepage/Faculty/Pennebaker/Home2000/WritingandHealth.html

Conclusion eCounseling is therapeutic communication that takes place over the internet. The written form of communication is very flexible and allows a counselor and client to 'meet' any time of day no matter where the two are located on the globe. There are pros and cons to this form of communication, and it does not appeal to everyone. Yet for people who do access eCounseling, it offers convenience, confidentiality, and a way to 'compose themselves' they can find at their fingertips.

Reference 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. http://homepage.psy.utexas.edu/HomePage/Faculty/Pennebaker/ Reprints/Pennebaker&Chung_FriedmanChapter.pdf

About the authors Cathryn Heyman is a Licensed Professional Counsellor in Austin, Texas, certified in distance counselling. As a former programming analyst and technical writer, Cathy uses technology to serve the human element in her online practice. Cedric Speyer helped design Shepell•fgi's groundbreaking E-counseling service based in Toronto, Canada. He supervises an E-team of 40 online counselors. Cedric champions a therapeutic approach called InnerView. Personal practices include meditation and Reiki.

TILT – Therapeutic Innovations in Light of Technology

R e s earc h R e v i ew

Post! Mind what you


elcome to the first research column, which will highlight reports of research studies into life online, online therapy and methodological issues related to online research. In this edition, I will mention just one study that reveals an intriguing aspect of online life: the habits of people in maintaining a social networking presence online seem accurately to reveal aspects of their personality – a hot topic for any therapists who have an online life outside their professional persona. Social networking is commonplace and continues to grow. It has been estimated that 1 in 12 of the entire world’s population - men, women and children - now have a Facebook profile [see http:// www.facebook.com/press/info.php?statistics for more details] with the average Facebook user being connected to 130 others. Applications like Foursquare may allow people you don’t even know to track you down in bars, cafés or even your home [Hickman, 2010] and there are increasing numbers of alternative social networking opportunities.

Therapists who practice online and also use social networking sometimes fall foul of dangers they may not have predicted. You may be careful not to post anything but the most professional of statements but your acquaintances and friends may not realise the importance of saving your blushes. That party you attended where you let your hair down in your teenage years may re-emerge quite possibly without your knowledge, let alone consent and


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reveal you in a way quite different from the image you would want to project to colleagues, let alone clients, and those too may become part of your public, or semi-public, Internet presence while removing them can be a difficult task. It is not only what others may post about us that can be revealing. What we say about ourselves is just as important. A study by the Universities of Mainz (Germany) and Texas (USA), reported in the journal Psychological Science (Back et al., 2010), has shown that people tend accurately to reflect their real selves in designing their online presence, revealing aspects of their personality. Many people might expect a little creative manipulation of one’s image by use of a photograph from a few years ago, or a description of a happy and successful approach to life that is not the whole story. But this does not seem to be as much the case as might be thought.

The study compared personality traits such as openness, extroversion, conscientiousness and agreeableness, as recorded by both the individual themselves and a small group of their close friends, with ratings generated by the researchers after examining the person’s Facebook profile. The match between the researcher’s guesses and the actual personality test scores was not exact but was significantly higher than would be expected by chance. The exception was assessment of neuroticism, which varied more greatly, but which

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S t e p h e n G o ss is in any case difficult to assess accurately. So therapists who have an online life should be aware that anyone who comes across their profiles may be getting a real insight into who they are beyond what they have deliberately chosen to present. We reveal our real selves, it seems, rather than an idealised version and furthermore our personality traits are open for others to judge. Genuineness and transparency in therapy are desirable, of course, and seem to be present to a greater degree online than we might have guessed. Your clients, friends and colleagues who access your information are likely to be getting to know the real you. The content may not only be of interest to your employer, colleagues and acquaintances but also to your current and prospective clients. Eventually, most practitioners will have among their clientele a few individuals whose interest in information about their therapist is not entirely benign, appropriate or respectful of boundaries. At the very least, you are likely to be ‘checked out’ and information will be used in ways you cannot directly influence. References Back M.D., Stopfer J.M., Vazire S., Gaddis S., Schmukle S.C., Egloff B., Gosling S.D. (2010) Facebook profiles reflect actual personality, not self-idealization. Psychological Science. 21(3):372-4. Hickman, L. (2010) How I Became a Foursquare Cyberstalker. The Guardian. 23rd July, 2010. [Accessed 4th August, 2010]. Available at http://www.guardian.co.uk/technology/2010/ jul/23/foursquare 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. Please send reports of research studies, planned, in progress or completed, to editor@onlinetherapymagazine.com, Subject line: Research Review.

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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, as well as our own considerations about what the issues are.

What Would You Do? Here’s the dilemma 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?! Weigh in at the OTI Social Network’s discussion forum! http://onlinetherapyinstitute.ning.com/forum/ topics/what-would-you-do-selected


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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 (see A Day In The Life Of An Online Therapist) 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 http:// talesoftherapy.wordpress.com/ - 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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TILT – Therapeutic Innovations in Light of Technology

DeeAnna Nagel and Kate Anthony


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Alice in V

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Alice got off at the subway station and decided to stop at the corner coffee shop instead of heading straight home. She has been traveling this route for over 20 years and she admits now to anyone who will listen, that the daily routine of her real life has become mundane. She grabs a cup of coffee - late in the day for her - but she knows what the evening holds if she returns home now. Anything, she thinks, is better than sitting at home all alone. So she opts to sip her coffee outside and people watch or, more likely, she will stare past people as they walk by. She is aware of the void inside but she is at a loss for what to do. Her 17 year old daughter, Lori, graduated from high school in the spring and is now off at college on full scholarship. Alice is so proud of her. Lori is studying architecture at a prominent school that is a short plane ride and only a ½ day’s drive away, but that is not the same as having Lori at home.

Alice’s husband, Ben, has worked for the airlines for as long as they have been together and in these most recent years he has opted to fly international routes which means he is sometimes gone for over a week at time. Due to shifts in time zones, Alice and Ben rarely get to talk when he is away. Occasionally they will Skype with one another and that makes Alice feel closer. She recently bought a new laptop with a built in webcam and an Internet air card from her mobile phone carrier so she can easily connect if Ben is available for a call. She can sometimes connect at work on her breaks too and even though she has permission to use her computer at work, she prefers the privacy of her laptop just in case her company has

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installed a keylogger program on company computers. After 20 years as a copy editor at the same publishing house, she feels secure at her job, but still, she does not trust corporate culture and covets her privacy. She has edited too many spy novels not to be at least aware of the technology available to corporations and business owners.

Tonight will begin the long weekend—a battle between loneliness and the lure of the computer. Alice likes her job but is not particularly challenged anymore. After she received her degree in journalism she got married to Ben and shortly afterward, she landed her current job. She took a long leave for over a year when Lori was born, and when she returned she was welcomed back into the workforce. She enjoyed her job for many of those years but she never aspired to move up within the company. Instead, she always dreamed of becoming a mystery writer herself. To that end, she received her master’s degree in creative writing just a few years ago. She enrolled in an online program and an entirely new and richly diverse world opened up before her. She became fast friends with many of her classmates in her program and while they have never met, she maintains contact with most of them through Facebook.


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Her closest friends from work have also “friended” her on Facebook and she is very pleased that Lori has embraced her as a “friend” as well. Being friends with Lori allows her to feel close to Lori while she is away. She loves reading Lori’s status updates and seeing the pictures Lori posts from school. Alice remained motivated about writing a novel and she began to use the Internet as a tool for networking and for motivation. She joined writer’s groups and she created a LinkedIn Profile. She opened a Twitter account and she even began blogging. Her blog site is a series of short stories that she composes and she has quite a few followers. Her online reputation has grown immensely and between her Twitter followers, her LinkedIn contacts and her Facebook friends alone, her circle of colleagues, friends and acquaintances has grown into the thousands. For many years, she was considered “Super Mom” and was revered by friends and neighbors. Ben and Alice frequently entertained and Alice was always involved in Lori’s projects. But when Ben’s job took him away for a week or more at a time, Alice found herself feeling sad and lonely. Her time online increased. When Lori left, Alice was consumed with a sense of loneliness and despair that she could not describe. She suddenly doubted if anything had any meaning and sometimes she felt her life had none apart from the relationships she has formed online.

On this particular day, Alice has paused at the coffee shop. She knows that when she is home, she will feel that empty feeling again. It is Friday. Lori is likely going out with friends in her college town and Ben is away on another trip. She has the entire weekend alone. Her weekends lately have been consumed with the Internet; the usual networking and Facebooking, but now she finds herself drawn to gaming. She is fascinated by World of Warcraft and one of her game partners in WoW has encouraged her to join Second Life. She has spent many days and hours online and she is concerned that she feels afraid to be without the constant distraction the Internet offers her. These past few evenings she has sworn off the computer, which has left her filled with an indescribably empty feeling. Tonight will begin the long weekend- a battle between loneliness and the lure of the computer. She just does not understand. She never knew she was so fragile – so unable to be in the company of herself. Alice sips her coffee and finds some solace in knowing that she called a counselor and set up an appointment for next week. The first available appointment was on Tuesday. She called at the beginning of the week knowing what she would face with the long weekend ahead. She had so hoped she could speak to a counselor before the end of the work week. But it didn’t happen so she has to face herself for a few more days before she can talk to the therapist.

Lucy had received an email inquiry from a potential client earlier in the week. The email said, “I am really at a loss. I feel lonely and empty now that my daughter is away at school. My husband is gone for a week or two at a time too. I am finding that I am spending more and more time on the Internet. Anyway, I think I need to talk to somebody.” Lucy often receives emails from people who are seeking services now because she is listed on several online therapist directories. She also has a website. She prefers a phone conversation to determine the next steps so she emailed Alice asking for a phone number to reach her. “If you can give me your phone number, we can have a brief consult on the phone. This usually takes about 15 minutes.” Lucy is hesitant to continue a dialogue with potential clients or existing clients via email because she is aware that regular email is not secure. She has heard about encrypted services but she has been so busy with her faceto-face practice that she has not had a chance to look into it. A few of her clients have recently requested online sessions due to scheduling difficulties. Since Lucy does not feel comfortable providing services online, she has offered phone sessions to these clients when they have been unable to come in person. She thinks of phone sessions as a viable alternative; after all, she worked a crisis hotline years ago so she is very comfortable with the phone as a way to delivery therapy. After Lucy spoke with Alice, she deduced that Alice is probably

going through the empty nest syndrome and her husband’s travels are complicating the transition. She was not too concerned about Alice’s description of her Internet use. Alice had said during the initial telephone consultation that she spends hours online finding herself “lost in a world that is frightening yet somehow chillingly familiar.” Lucy makes note of the description and decides she will only pursue that angle if Alice brings it up again. For now, she thinks she will talk with Alice about her feelings regarding her daughter’s recent departure and how her role as mother has shifted. Lucy has been practicing counseling and psychotherapy for nearly 20 years. She worked in several settings that required hands-on counseling and case management experience and she has supervised several interns along the way. About six years ago, Lucy decided to go into private practice, having worked in agency settings since she obtained her graduate degree. Her interests in the field focus primarily on survivors of abuse and trauma but in her private practice she identifies herself as a generalist. Still, with her psychodynamic background as a constant influence, she always presumes that unresolved issues are lurking. She has learned over the years not to look for trauma in every client though, and she is now quite comfortable meeting clients where they are at; those murky waters of childhood are sometimes left undisturbed.

For t h e first session Alice arrived early. Lucy had said there would be paperwork to fill out. Alice had never been to a therapist before so she was not really prepared for the questions that stared back at her from the clipboard. Most of the information was straightforward but when the questions about whether or not she had been sexually abused stared back at her from the page…that really sent a jolt through her. She had. And why does she need to reveal it?? She was instantly put off. She came here to talk about the Internet, NOT the bleak moments of her childhood. And besides, if Alice did not want to discuss it, then why ask? Her mind began to race as she finished the rest of the form, giving short

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and less than revealing answers. The last question on the form gave her pause. It read, “Is there anything else you would like for me to know?” She thought about writing, “Well, not just yet, thank you…” But instead she wrote two words. “I’m scared.” Lucy noticed Alice’s posturing; arms crossed in front of her, sitting on the edge of the sofa. She sensed that Alice was unnerved. Lucy welcomed Alice and introduced herself. Lucy explained that she was a Licensed Professional Counselor with a graduate degree in community counseling. She went on to tell Alice how she works, what her general style is and that she uses the first session to establish comfort and safety. Immediately Alice shifted her gaze from the clipboard in Lucy’s hand to Lucy’s eyes. Lucy took the opportunity to elaborate. “Alice, I realize I asked you to reveal a lot of personal information this morning. You filled out pages and pages of questions and that was before we really had a chance to meet. So I just want to acknowledge how difficult that can be for some people. It might even leave you feeling a bit vulnerable. So I want to be sure that you know your information and your personal history is safe here in this space and with me.” Lucy noted an immediate response. Alice sat back and uncrossed her arms. Lucy spent a few minutes reviewing the informed consent and discussed how to contact her between sessions in case of an emergency. She gave Alice her cell phone number indicating this as the best


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way to reach her. Lucy and Alice met for 50 minutes each week. They discussed Alice’s feeling of emptiness now that her daughter is away at college. They talked about her job and her dream of writing a mystery novel. Alice would occasionally bring in bits and pieces of her short stories to share in therapy because she would often use her own life to portray a certain scene or create a character in the story. For instance, her most recent mystery was set in Appalachia in the sixties and

She came here to talk about the Internet, NOT the bleak moments of her childhood. in describing the house and the land, she had pulled from her memories of her own childhood. She thought that by sharing those few paragraphs with her therapist, it might help her therapist understand her better. Lucy would often take Alice’s lead and guide her toward her past particular moments or feelings - especially those lonely feelings Alice would repeatedly describe. Lucy also noticed a thread of lonely characters in Alice’s stories. Alice would often summarize her latest blog story and between the short summaries and the snippets that Alice would bring in and read, Lucy would often

find herself overwhelmed by the loneliness Alice carried with her. For months Alice and Lucy talked about the lonely feeling. Alice had no recollection of abuse or particular neglect at the hands of her family. She was molested by a neighbor across the street when she was 11, and while she and Lucy talked about the significant impact this had on her life in many ways, Alice just could not identify the lonely feeling she had as being connected in any way to that event. And so, they kept talking. Alice was very comfortable with Lucy and trusted her. She was so excited to see that Lucy was on Facebook. She did a search and saw her profile picture. She also saw that Lucy had joined a Facebook support page for parents of children with autism and saw that she was also a member of several environmentalist groups. A few weeks later after Lucy had not returned Alice’s request for friendship, Alice asked Lucy about it during their therapy session. Lucy logged on to Facebook. She loved Facebook because it enabled her to stay in contact with her close family and friends. Lucy hardly used the Internet at all but her sister had talked her into joining Facebook and even showed her how to sign up and get started. When Lucy saw Alice’s request for friendship she did not know what to do. She was stunned that her client would want to be connected in that way. For the time being, she decided to ignore the request and take it up with

TILT – Therapeutic Innovations in Light of Technology

Alice only if she asked. Then, just before a session with Alice, Lucy was reading an article in a counseling magazine and read that it might be unethical to friend a client and further, therapists might consider explaining social networking boundaries with their clients during the informed consent process. Lucy was not really sure what social networking was, but she knew that Alice had recently asked for friendship. Lucy went on to read that clients might frequently friend their therapists because clients don’t understand the ethical responsibilities of their therapists. With that, Lucy thought it might be wise to explain that she did receive the request but she opted not to return friendship because it might be considered a dual relationship. Lucy had not thought that friending a client might also compromise co n f i d e n t i a l i t y. She was a bit

concerned about her Facebook profile after reading the article. The article advised that therapists should be aware of their profile security settings. She did not know quite what to do so she decided she would call her sister. Before Lucy could address the Facebook issue in their next session, Alice asked Lucy, “I friended you on Facebook but you never accepted. Do you go online much?” Lucy explained why she did not accept the friend invitation based on the article she had just read and told Alice she mainly used her computer for word processing. “Oh. So you must think I am really strange going on and on all these months about my avatar and Second Life stuff.” Suddenly Alice felt unheard and out of place. For the first time since she started seeing Lucy she felt exposed. Lucy said “Alice we have talked about many things since you began therapy, including y o u r game

issues.” Alice was quiet. Lucy did not quite know what to make of the silence. She could not understand Alice’s reaction. Lucy sat with Alice in the silence. Alice’s eyes teared up. Lucy finally asked, “What are you feeling, Alice?” Alice looked away and stared out the window, tears now streaming down her face. She replied with a tone completely void of affect, “You don’t get me…all these weeks I have been talking about all my stuff, but a lot about my other reality. I even told you about my avatar. I thought it was odd that you didn’t latch onto that piece. I mean, I thought it was perfect – that I was willing to share with you this avatar - my persona, a part of me that I created online- I told you her name even.” Alice began to speak with a wavering and loud tone, “Do you remember?? Her name is Wendy and she is 11 years old. Well, anyway, you probably didn’t say anything because you don’t even know what an avatar is do you? I figured you were the therapist. You are supposed to know things better than me. So I just assumed we would circle back to Wendy. But we never did. Now I know why. You think she is just part of a silly game I play, don’t you?? To you, she has no purpose in here. But guess what, Lucy? She is real. She is real to me!!” Lucy felt for the first time in many years, that she really missed the mark. She realized in short order that she was unfamiliar with this context that Alice brought to therapy. Her mind was racing. She actually thought she might be working outside her scope


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of practice. Should she make a referral? Has she reached an impasse? But in those moments when Alice shared her true feelings, she also knew that she and Alice had made a connection so she hoped her authentic response would be a step in bridging this huge gap in Lucy’s knowledge base and that she and Alice could continue to work together. “Oh Alice. I am truly sorry. I was working off the emotions you were bringing into our sessions and I admit I did overlook your mentions of Wendy. You are right. I don’t understand because I don’t know about this other reality you have spoken of, and that is shortsided on my part. I should have asked more questions and allowed you to lead us to what is obviously important. Would you be willing to show me and guide me to this place you talk about?” Alice wondered for a moment if she should even come back. She felt, in a word, invalidated. Ironically, she learned about feelings of invalidation from Lucy. But when Lucy admitted her mistake, Alice sensed that Lucy was speaking from a place of humility and recognized her own naivety. She asked Lucy, “Do you want to meet Wendy?” Lucy replied that she would be honored to meet Wendy. Alice said she would bring her laptop to the next session. Lucy explained that she did not have an Internet connection at the office and Alice assured her that would be fine because she would bring her air card. “Okay Alice. Thank you for being willing to bring me

up to speed so we can continue our work together. I think it might be helpful if I take a look at Second Life before our next session. I clearly have some catching up to do.” Alice had scheduled her next appointment 10 days later because she and her husband had planned a 3 day trip to visit their daughter. Alice felt surprisingly empowered after the session, knowing that she had stated her true feelings and that now she would be able to explain to Lucy in a way that she had never explained any of this to anybody. She actually looked forward to their next session. Lucy felt incredibly overwhelmed after her session with Alice. Facebook, Internet, avatar, air card…her head was spinning. And she was a bit scared that she would not be able to come up to speed and truly understand. She had logged on to Second Life that evening after her session with Alice and she felt confused, like she did when she was in algebra class in seventh grade. She signed up for an account but then she was asked to download a program and her sister had warned her not to download too many more programs because her computer was several years old and did not have much space or memory or something like that. She had heard recently of Avatar, the movie. She saw the previews but that did not make much sense to her either so she didn’t see the movie because it looked like science fiction and that was

not a genre that usually held her interest. She thought perhaps she needed to seek guidance on her case with Alice, but from whom? She decided to call her long time mentor, Dr. Alan Finster. “Hi Al, I know it has been a while. I have a case I would like to discuss with you. Can I tell you briefly? I don’t know if this is a situation you can help me with or if you know someone I can talk to? I am just at a loss. This is all so new.”

She realized in short order


unfamiliar context







brought to therapy. Dr. Finster couldn’t think of anything that would be “so new” as to be out of his range of knowledge and expertise. Nearing retirement, he figured he had seen and heard it all, especially with supervisees and consultees who came to him to discuss transference and counter-transference issues. He had consulted with Lucy over the years having met her when she was in graduate school. He was her first clinical supervisor at Lucy’s internship placement. Since that time she would call on him as necessary when she felt she was struggling with a case. She had never presented a case to which he was unable to offer clear direction. But when he heard about Alice and her expression of what sounded like an alter she had

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created in this game setting, he knew he was not amply prepared to guide Lucy appropriately. “Lucy, this is probably a different answer than you were expecting, but it sounds like you are dealing with an unknown set of cultural morays. It is as if you have said to me that your client is from another country that you don’t know anything about. And unfortunately, this country is one I don’t know about either.” Lucy immediately resonated with that description. “Yes! That is exactly what it feels like! It is like I don’t know the terrain - I can’t even visualize it! But if it were another country, well I could look up pictures of the terrain, I could read about the culture but this, I don’t know where to even start.” Dr. Finster paused and said, “You have started. You have accepted an education from your client and that will likely be rich and informative. Now you need to seek out additional resources. I will see what I can find out. Do you mind if I ask around? And perhaps you can do the same.” Lucy called her sister next. “Anne, do you know anything about Second Life? You know how you got me on Facebook? I need to go to Second Life. And what’s an air card?” Anne invited Lucy over Saturday afternoon. She said she could show Lucy Second Life, “I have been in Second Life. It is pretty cool, actually. I just haven’t had time to really explore. This will be a good excuse! And fun too! I don’t think your laptop has sufficient memory to run Second Life, but we have my laptop and


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the desktop here at the house so you and I can both be on.” Lucy was greatly relieved. At least she would be able to see this other world that Alice kept referring to. “Anne, thank you. Can you explain other things to me like social networking?” When Lucy visited Anne, she indeed saw and walked in Second Life for the first time. It was such an expansive experience and she was struck with this entirely new and different view she would have never have had, were it not for her client. She reflected on how her clients had taken her to new and different places within herself many times over the years, but this was so very different. And she couldn’t wait to tell Dr. Finster that it is not another country, this Second Life thing - it is another world!!

She was filled with new energy and a better understanding of what Alice would present to her in their next session. Lucy began to wonder about life in this other world and as she walked through Second Life, visiting a coffee shop, a jazz club and a shopping mall, she paused. She thought about Wendy Wendy, walking around in this huge, endless world…alone? She is 11 years old! She began to feel protective of Wendy and remiss in

her duties as a therapist, reflecting on how her own ignorance nearly caused irreparable damage to the therapeutic alliance with Alice. Even so, she was filled with new energy and a better understanding of what Alice would present to her in their next session. She just felt that she needed to talk to a therapist who may have experience in this realm. Lucy searched the Internet using various terms. She did not really know what to name what she was looking for, although she had heard terms like online counseling and e-therapy before. In her search she came across a couple of prominent names in the field that surfaced over and over and she found an organization’s website that offered articles and information on topics related to mental health and technology. She also searched major online bookstores like Amazon and found valuable resources. Over the next week she poured through websites, read articles, and contacted a couple of “experts” for a one-time consultation. She found online courses that offered continuing education. She even ran across references to “Avatar Therapy.” What she learned in just one week was the beginning of a major paradigm shift for Lucy. She started to envision her work with clients in an entirely different way. Signing up for encrypted email was as simple as setting up a Yahoo or Gmail email account. She could give homework assignments and additional readings via email between sessions. She could even

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offer her clients online sessions through video conferencing and chat. She realized the learning curve but after exploring Second Life, cyberspace did not seem as intimidating to her and she was interested in the exploration. In fact, she was considering buying a new laptop, but she would not have this in time for the next session with Alice.

with Wendy at introductions for today. Alice agreed and after Alice shut her laptop, they discussed feelings Alice was having about introducing Wendy to Lucy and how they might proceed with further sessions. Alice asked if Lucy would be willing to join

session instead of using the chat component of Second Life. Lucy thought they might progress to working from home, with Lucy and Alice on their respective laptops, logging on from remote locations and the consultant recommended using a chat/voice option that is encrypted to layover Second Life.

Lucy was keenly aware

Alice arrived at her next appointment with Lucy on time. She was very excited but timid about introducing Wendy to Lucy. Lucy welcomed Alice. She told Alice that she had done some research and visited Second Life. She thanked Alice for her patience and told her that she was determined to get up to speed. Alice set up her laptop and used her air card to access the Internet. Within a few minutes, Alice was online and in Second Life. With Alice and Lucy both positioned on the sofa, Alice placed the laptop on the coffee table in front of them. Alice said, “This is Wendy.” Lucy saw an 11 year old version of Alice with the same color hair, freckles, a small nose and a dimple in her chin. Lucy was struck with the sense that Wendy was in the room with them. She immediately felt the need to remind Alice (and Wendy) that they were both safe in this therapy room. She wanted to be able to process this introduction without delving too much further. She suggested to Alice that Wendy might need time to become comfortable with Lucy and said that perhaps they could just leave the interaction

of how free and unin-

Over the next few weeks, Lucy and Alice met in the office. Lucy purchased a new laptop and enabled her office with Internet access. Lucy joined Wendy in Second Life and Wendy spent a couple of sessions taking Lucy to her favorite places. She had created her own home, complete with furnishings and her favorite foods in the kitchen cupboard. It became clear that these places that Wendy showed Lucy were all safe, warm and without conflict. The home was the home of Alice’s childhood. Wendy said, “When my parents are home, they are here in the living room reading the paper.”

hibited she felt and how easy it would be to communicate much more casually with Wendy. her inworld and Lucy explained that she was exploring ways that they could accomplish this but she wanted to do a bit more research. Alice thanked Lucy for her willingness move into a new frontier. Lucy was able to secure a consultation with a person who had knowledge of virtual worlds and avatar therapy. She talked about the case of Alice but also asked technical questions about working in environments like Second Life. The consultant suggested to Lucy that perhaps she continue in a similar fashion but perhaps work from her own laptop in the same room with Alice. The consultant explained that Second Life is not encrypted but since they will be sharing the same space face-to-face, that they might talk within the

When Lucy and Wendy finally met inworld without the physicality shared by Alice and Lucy in the office, the conversation deepened and the information shared became much more intimate within minutes. Wendy and Lucy traveled around, Wendy showing Lucy new discoveries in Second Life. Lucy was keenly aware of how free and uninhibited she felt and how easy it would be to communicate much more casually with Wendy. She literally had to imagine herself as the therapist she is, picturing her office space and the chair she sits in to remain centered and focused while she

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emotions and brings her back fully into the present. Alice is coconscious and aware of what just happened. Alice whispered, “Soul murder...that’s what happened to me. I have been searching for my soul…he took it. Wendy is the me before the murder. She is free and light and…” Lucy said gently “And you can be free and light again Alice.”

worked with Wendy. At the end of this session, Wendy said she had created more buildings and streets and teleported Lucy back to her home. Wendy had created a street with trees lining the road and another house across the street from her own. Lucy immediately recognized the significance of the house across the street and suggested that she and Wendy take a walk “to that very pretty meadow you found. Let’s close the session there. And then I want to ask you if it is okay for Alice and I to have an in-person session again before I meet with you here? We can come right back to this meadow.” At their next in-office session, Lucy and Alice caught up on Alice and Ben’s trip to see their daughter. Alice also talked about her mystery writing. She said that her latest story involves “the house across the street. You know, the one Wendy showed you in Second Life.” Alice asked why she chose that house as the house in her mystery story and she said, “Well, the house


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that Wendy created in Second Life is the house I was molested in when I was 12. Since that house has bad memories for me, it makes sense that it would be the perfect place for a murder in my next story. A young girl is murdered there.” Lucy asked if there was any significance between Wendy creating the house in Second Life and Alice writing about the house as the scene of a murder and Alice replied, “I don’t think so.” Within seconds, Alice was clenching her fists, rocking and shaking with her eyes closed. Lucy reminded Alice where she was, that she was safe and asked her, “What do you see?” Alice replied, “it is not what I see, I mean, I have seen this house, well I mean, I don’t know, I was just there, in the house. Wendy took me there inside…you know, in Second Life, but now I am there again, I mean it is me, or Wendy, oh I don’t know. And he is there, and he is hovering, oh I just know I am going to die. I think I will just die if he touches me, oh my God.” Lucy contains Alice’s

“I mean, my parents didn’t show me a lot of attention. They read the paper a lot. But I never felt like they meant to hurt me. I knew there was something - I don’t know, it is hard to explain. I have always remembered what happened. But today, I remembered it differently. I remembered how I felt - that it was wrenching, that it left me emotionally empty and I have been so lonely searching for myself all these years. And Wendy, she is so innocent.” Lucy offered to meet Wendy in Second Life for the next session. “Alice, why don’t you think about how you would have liked things to be different? “Well, I would have liked to have not been molested.” Lucy sat on the edge of her chair and proclaimed, “And so it is.” “Whatever do you mean, Lucy??” “Let’s let Wendy show us a different ending to this story. She can take us in the house. You will be safe because I will be there and besides, this did not happen to Wendy.” “But Wendy is a part of me.” Alice said. “And Wendy has something to

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share with you Alice, so let’s see what she can reveal to you.” Lucy offered Alice the opportunity to email if she began to feel overwhelmed. “I will check in with you as well. Remember to use your encrypted email account. Reach out if you need to. I might not read it right away and you have my phone number if it is an emergency. But feel free to email me before we meet again. This has been an intense session and I want you to know I am right here.” Seven days later, Wendy and Lucy met in the meadow in Second Life. The meadow was full of poppies and shasta daisies all abloom. Wendy talked with Lucy about how wonderful things have been. “You remember I told you I have a best friend? Her name is Maggie. She is my age and guess what?? She lives right across the street!” Lucy and Wendy teleported back to Wendy’s house. Wendy walked across the street and Lucy followed. “Maggie isn’t home right now but I just wanted you to see! Go in! Maggie and I have the most fun ever here! This is one of my favorite places in the whole wide world!” Lucy enters the house full of pastel colors. Cupcakes and cookies lined the kitchen counter and a huge doll house was set up in the living room. There were balloons everywhere. “What are the balloons for Wendy?” Wendy replied, Oh, we had my birthday party earlier today! I am 12 now!” Alice, sitting at home, led by Wendy’s unwavering quest for fun and harmony, felt reborn in that moment. Her soul was alive again and the trauma she had experienced washed away as If it never happened. The feelings of loneliness that had engulfed her as she searched for herself were gone. Wendy had been able to reframe the entire experience for Alice turning her 11th year into something to celebrate instead of regret. Lucy and Alice continued to work together and processed these events over the next couple of sessions. Alice’s driven desire to be inworld and online passed over time and when she did go into Second Life, she would allow Wendy to show her all of those safe and fun places they shared. Whenever Alice felt unsure or unsafe, Wendy was there to show her life and remind her of the incredible soul work that was accomplished in a virtual world. DeeAnna Merz Nagel and Kate Anthony are co-founders of the Online Therapy Institute and Managing Editors of TILT Magazine ~ Therapeutic Innovations in Light of Technology. Illustration credits: Artwork by Jokay Wollongong Avatar by Jany Bluebird

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Jean-Anne Sutherland


wo lovers struggle against and with their passion for one another. Their lives are such that they can’t say it out loud – can’t claim one another in their day-to-day lives. Separated, their thoughts turn to one another. Together they know a passion, a connection and a love they’ve yet to find with another. Jack is ready to claim the relationship in his life but Ennis remains locked in fear. His angst concerning social condemnation ensnares him in denial. Jack, aware that he can’t push Ennis to a place he is unwilling to go is reduced to anger and tears. Tired of their separation, emotionally depleted by the hopelessness of their passion, Jack says to Ennis, “I wish I knew how to quit you.” That line, “I wish I knew how to quit you,” has become a kind of iconic symbol of a gnashing, impossible and seemingly impossible love. The movie (Brokeback Mountain 2005) and the line struck a chord with audiences – tapping into feelings of loss, hopelessness and contradiction. Gay or straight, viewers of this film have the opportunity to come face to face with relationships dynamics, the integration of identities, feelings of loss, heartbreak, and a visual representation of the price of fear. Increasingly therapists and academics use film in their work in order to illustrate concepts, conditions or experiences. While myths once served to illustrate the beliefs, values and behaviors of its people, films now provide us with glimpses into our culture. Like literature, movies instruct, entertain, offer principals and ideologies, values and, life lessons. Films can both reinforce stereotypes and challenge viewers with new interpretations of old themes. Films show

us the development of individuals as they struggle with identity and self-esteem. In movies we watch characters interact within the contexts of relationships. Films are a new kind of “text” through which we are provided stories, frames, and representations of social life. Just as mental health professionals have long integrated other mediums such as literature and music into counseling, films provide an opportunity for clients to view the representation of an otherwise abstract idea. Therapists know that people are more likely to view a movie about addiction than to read a text about the subject. At present there are multiple texts and websites for specific instruction concerning film and therapy. Resources range from the specific “howto” to the theoretical. It follows that as access to films expand, use of film in the therapeutic setting will increase. Important considerations involve appropriate “readings” of films – placing them within the larger social and historical context in which they are produced. While films strike at the heart of issues, they don’t themselves capture the complexity of the issue. Films are an ideal tool for illustrating life, pain, loss and, joy. The work of the therapist is to frame those representations in such as way as to provide meaningful analysis for the client. As Buddy (Kevin Spacey) reminds us in Swimming with Sharks (1994) “Life is not a movie. Good guys lose, everybody lies, and love... does not conquer all.” 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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TILT – Therapeutic Innovations in Light of Technology

Jason S. Z ack

Is Online Counseling Legal? Is online counseling legal? Unfortunately, there's no simple yes/no answer, any more than, "Is driving legal?" or "Is counseling legal?" The fact is, it depends on where it's being done, who is doing it, and what exactly is being done. Add to that the fact that (1) you can do something specifically illegal in the course of doing something generally legal, and (2) an activity might be legal but still expose you to civil liability or other negative consequences. Ultimately, as in any other complex human endeavor, when it comes to online counseling you must consider the context and use your judgment to decide whether the level of risk weighs in favor of undertaking the activity. You'll need to consider several factors, outlined below:

Where When it comes to legality, the best place to start is "Where" because geography determines what governing body has jurisdiction over what you're doing and that governing body (or bodies, to the extent more than one applies) makes the laws that you need to consider. As much as we can imagine an abstract internet


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where things happen everywhere and nowhere, you and your client are still people who will be sitting or standing or lying down or moving around while they are engaged in the online counseling process (to say nothing of courtrooms or prisons). Just think about which jurisdiction's police officers or judge would have the power to affect your life. States are generally pretty cooperative in helping to track down criminals from sister states, and nations vary depending on their relationship. If the counselor and client reside in the same legal jurisdiction, then the analysis is simple, but less so where the parties are in different states. The point: figure out what jurisdictions might apply and become familiar with those laws. Consider not only the jurisdictions where the parties reside, but also the location where the activity is occurring. Consider both the laws of the state (e.g., practice laws) and the country containing it (e.g., privacy and other healthcare-related laws, especially with interstate or international transactions). Act in accordance with the more restrictive jurisdiction where possible.

Who The most obvious way that online counseling might be illegal is if someone unlicensed is doing it. Indeed, the unlicensed practice of psychology, or social work or any other licensed profession is illegal in most states. If it's illegal to do something offline, a judge will probably say it's illegal online too and a number of states have explicitly added language like, "by any means" to their practice definitions. Some states have also explicitly prohibited the delivery of medical services to residents from outside the state by providers who are not licensed within the state. That said, many states also have temporary practice provisions allowing licensed professionals from other states to work for a short period of time within the state. States (and prosecutors) vary in how vigorously they enforce practice laws. Note also that many countries outside the United States have no formal license requirement for professional mental health counseling.

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What Assuming you're comfortable with the legality of the practice of online counseling in the applicable jurisdictions generally, then the primary consideration will remain making sure you comply with any laws applicable to conducting professional mental health counseling by any modality. Some of those laws may be more or less difficult to follow by virtue of the online modality. Specifically, the counselor must comply with any state regulations re. privacy, consent, note-keeping, crisis management and reporting (e.g., suicidality, abuse).

You Can Do This Ignorance of the law is no excuse, but there is a general principle that criminal statutes should be easily understandable to the public. Although statutes are interpreted by case law in the U.S., and courts flesh out vague language, you shouldn't need a lawyer to figure out the basics of what you can and can't do. The good news is that nearly every state and the federal government makes its laws freely available to the public via the World Wide Web. Before you start online counseling, take some time to skim the mental health laws of your state (which you should already know) and the laws of your client's state, if different. Just enter the state name and "codes" or "statutes" in your favorite search engine--they're often found on the website for the state legislature. Most states make it very easy to search their laws by keyword or a detailed table of contents. It's also a good idea to visit the website for the state board of psychology (or social work or mental health counseling), as they generally collect all of the relevant mental health laws in one place along with links to any potentially applicable regulations for counselors in that state.

Beyond Criminality A final consideration is that, even if online counseling is conducted in a manner that is perfectly legal (or not enforced by the governing body), considering

each of the factors above, there may still be legal consequences in the form of civil lawsuits based on contractual disputes, fraud, negligence, etc. I've written elsewhere about these considerations. If not careful, online counselors may also run the risk of having to answer to regulatory agencies like state Boards of Psychology that mandate compliance with ethical codes and other rules.

Conclusion In sum, it is impossible to say whether online counseling is illegal or legal as a general matter, but with some careful consideration to several key factors--including where the parties are located, who is involved and what is being done--there are myriad ways to practice online counseling in ways that would be considered legal or illegal. Finally, it is important to stress that just because an activity is not a crime, that activity may still carry consequences for the participant. 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 with the author and anyone reading it.

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Ma r i n a L o n d o n

Opening Therapeutic Doors to the iGeneration A

ccording to an article in the New York Times (Stone 2010), researchers are beginning to draw a distinction between the Net Generation, born in the 1980s, and the iGeneration, born in the ’90s and this decade.

Now in their 20s, those in the Net Generation, spend two hours a day talking on the phone and still use e-mail frequently. The iGeneration — conceivably their younger siblings — spends considerably more time video chatting than talking on the phone, and tends to communicate more over instant-messenger networks. The article further elaborates: "the ever-accelerating pace of technological change may be minting a series of minigeneration gaps, with each group of children uniquely influenced by the tech tools available in their formative stages of development. 'People two, three or four years apart are having completely different experiences with technology...College students scratch their heads at what their

high school siblings are doing... It has sped up generational differences.'” These mini generations are different from each other and from the Boomer and Xers that precede them. As mental health professionals, why should we pay attention to these micro generational differences? Well very soon, these young people are going to become our clients. If we want to help them, deliver therapy to them, coach them – we will need to understand their unique relationship with technology, and as clinicians, be prepared to harness technology to deliver services. As clients, it is easy to imagine that they will be receptive to cutting edge therapeutic delivery models. They will be open to online counseling, whether via e-mail, instant messaging or video chat. They will probably even enter a virtual world like Second Life to get information about resources, and down the line to receive confidential and encrypted avatar therapy. In their lifetimes, who knows what other methodologies will be available to them? T I L T M A G A Z I N E S e p tem b e r 2 0 1 0


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Other iGeneration traits that will probably have implication for psychotherapists: • The newest generations, unlike their predecessors, will expect an instant response from everyone they communicate with, and won’t have the patience for anything less. “They’ll want... [everyone] ... to respond to them immediately, and they will expect instantaneous access to everyone, because after all, that is the experience they have growing up...” • They will make less of a distinction between their online friends and real friends – something that can be difficult for Xers and Boomers to fully understand. • They are fantastic multitaskers. Studies performed show that 16- to 18-year-olds perform seven tasks, on average, in their free time — like texting on the phone, video chatting and checking Facebook while sitting in front of the television. People in their early 20s can handle only six, and those in their 30s perform about five and a half. How is that working out in school and later on, in the workplace? Will they be able to focus? Will difficulties with commitment to task and personal relationships send them into treatment? • They have some relaxed notions about privacy. Information that Boomers and Xers kept under (literal) lock and key is freely shared on Facebook, posted on Twitter, and uploaded to YouTube. • This is a brave new generation who will never be “off the grid.” They have grown up with this technology, as opposed to the rest of us who had to learn it, while often unlearning something else. • It’s not yet clear whether these disparities between adjacent generational groups will simply fade away, as the older groups come to embrace the new technology tools, or whether they will deepen into more serious rifts between various generations. • The children, teenagers and young adults who are passing through this cauldron of technological change will nevertheless have a lot in common. They’ll think nothing of sharing the minutiae of their lives online, staying connected to their friends


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at all times, buying virtual goods, and owning devices for controlling all of these activities. They will not hesitate to participate in online therapy. The rising iGeneration presents a single critical implication for all mental health professionals the time for us to acquire knowledge, to become Distance Credentialed Counselors (DCC) or otherwise obtain expertise is now. I remember distinctly when computers were introduced into my workplace. It was 1991, and employees in my clinical setting were offered “optional” computer training. By 1996, computer literacy was no longer an option. Still hesitant about putting your toe in the online therapy waters?

Online therapy is: Effective: over fifteen years of research confirm that it’s is as effective as in–person treatment. (Edwards 2009)

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Convenient: 50% of therapy clients drop out after a few sessions, but research shows teletherapy can boost retention to over 90%. Because clients can hold sessions anywhere with phone or Internet access, they are much more likely to stay in treatment. (Edwards 2009) Affordable: telemedicine sessions can cost 10 to 50% less due to reduced overhead, travel time, and staffing needs. Accessible: research shows the fit between clients and mental health providers is essential to positive outcomes. Most people will not travel to a provider beyond fifty miles, but telemedicine lets clients work with the best licensed provider regardless of location. (Edwards 2009) Confidential: 80% of therapy clients worry about the stigma of treatment. (Edwards 2009) Email therapy’s earliest adoptees were in Asian countries where psychotherapy carries a very negative stigma. (World Update 2008) Legal: Online therapy is legal and expanding, and regulated by state–specific guidelines. Government and licensing boards are also rapidly evolving legislation to expand online therapy access. Currently providers only “see” clients in states where the provider is licensed. Providers can typically apply for licensure in multiple states, either directly through state licensing boards or third–party services that streamline the application process. Reimbursable: Teletherapy is reimbursable. Since 2004, Medicare and the AMA (American Medical Association 2010) have issued CPT codes to identify and reimburse online therapy services. A list of eligible services and codes include: • • • • •

Individual psychotherapy: CPT 90804 – 90809 Consultations: CPT 99241 – 99255 Office or other outpatient visits: CPT 99201 – 99215 Pharmacologic management: CPT 90862 Psychiatric diagnostic interview examination: CPT 90801

CPT code descriptions can be found on the American Medical Association's CPT directory. The modifier GT may be necessary to identify that services were delivered via telemedicine. More details on reimbursement are available through the American Telemedicine Association (American Telemedicine Association 2010). The time for optional online therapy literacy is almost gone. n About the author Marina London is the author of iWebU, (http://iwebu.blogspot.com), a weekly blog about the Internet and social media for mental health and EA professionals who are challenged by new communications technologies. She can be reached at MarinaL@ me.com.


American Medical Association 2010, CPT Coding, Medical Billing and Insurance, Available from: <http://www.ama-assn. org/ama/pub/physicianresources/solutions-managing-your-practice/codingbilling-insurance.shtml> American Telemedicine Association 2010, Private Payer Reimbursement Information Directory 2010, Available from: <http:// www.amdtelemedicine. com/telemedicine-resources/private_payer.html> Edwards, Brian T. 2009 ‘BreakThrough: Teletherapy startup gaining some mainstream popularity’, Connected Care Blog. Available from <<http:// connectedcare.posterous. com/breakthrough-teletherapy-startup-gainingsome>>. [19 September 2009] Stone, Brad 2010, ‘The Children of Cyberspace: Old Fogies by Their 20s’, The New York Times 9 January. Available from <http://www.nytimes. com>. [9 January 2010]. World Update (panel presentation) 2008, World Employee Assistance Professionals Association Conference, Atlanta, Georgia.

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an Online Therapist

A Day in the Life of

As I drive up to the elementary school to pick up my children, I resemble every other working parent at the curb. Silver “mini-mom” van doors slide open as my children slither inside, and off we go toward our afternoon activities – either grocery shopping or baseball practice or religious school or gymnastics.

Audrey Jung

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TILT – Therapeutic Innovations in Light of Technology

But I am not just any mom picking up my kids after school. I have an alter-ego. I am a psychotherapist who practices her craft in an office and on the world wide web. My day often begins at 5am, with a steamy cup of sweet coffee and a computer. As I sip and my eyelids respond more steadily to the caffeine, I check my email for any last minute changes to my schedule. I use online schedulers for both my face-to-face practice as well as for the clients that I see through an e-clinic. My next stop on the information super highway is to travel over to my social networking sites, picking up interesting psychological articles or news happenings and sharing them with friends, colleagues, clients and even some potential clients along the way. This morning’s article of interest centered on a computer hacker who created an innocuous profile and wormed his way onto the friends list of hundreds of military and intelligence professionals by claiming to be an analyst they knew. Using Hootsuite, I share this article with everyone in my Facebook, LinkedIn and Twitter contact lists, encouraging people to use this article as a means to open a dialogue with their children and their spouses about the importance of maintaining safety online. Spontaneously, an instant messenger window opens up, and a high school classmate comments that she saw the article, and has been experiencing something similar (a friend request by someone alleging to have been an acquaintance). We chat about this for a while, and my friend informs me that she has just given my name out to someone she met who has been “having a hard time.” I smile to myself – it’s not even 6am, and I’ve effectively marketed my skills. Off to the shower. By 7:30am, I am comfortably situated in my office, working with the first of my six face-to-face clients for the day. Many of these clients have been given my name through their company’s employee assistance program, or mental health insurance plan. Some have been referred by friends and physicians in the area as well. Most, however, inform me during their first session that they chose to make an appointment with


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me after seeing my website, www.AudreyJung.com, and deciding that they could connect with me on an emotional level. A few even confide that they used a search engine to hunt for my name, and were pleased with what they found. Just after lunch, I check my email, and find that I have an encrypted message waiting for me. This is a response from a client I have been working with online – someone who works third shift, and finds that counseling during traditional office hours is difficult for him to commit to, as he tends to be asleep (or very drowsy) during that time. I consult my calendar, and set aside a block of time to read, process and respond to his email session later in the afternoon. I respond to a discussion thread amongst the board members of a professional organization, set up a secure poll using our website platform, and call for a vote. I have found that a lot of good intentions can get lost in the internet “ether” if a structured approach is not taken toward organizational management – even if this organization exists solely online. My final appointment today is a video session scheduled through a secure, web-based platform. I set my laptop onto a special riser, so that my webcam will have better access to my face. I log into the online “meeting”, and await the client’s connection. We chat for the next 50 minutes, and I share some mental health models and resources that I have accumulated over the years. We discuss short term goals for the coming week, and the client promises to set another appointment online using the scheduler.

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The trickiest part of my day is about to approach – setting aside my work to balance my life with my family. I zoom off to the elementary school, and pick up my children. We chat about school, friends and bullies, review homework assignments and plan the weeks’ events. I cook dinner, cringe in hopeful expectation that the children will eat it, and then clean up the kitchen while the rest of the family heads off to prepare for bedtime. After tucking the tikes into their beds for a good night’s rest, I open my laptop and review the email that had arrived earlier in the day. I craft a response, encourage a chat session for additional exploration and append a few helpful psychoeducational links. This can sometimes take 30 to 50 minutes… imagine the time it would take you to write a 200 word essay on a technical topic of your choice. I encrypt the email and send it back to the client.

It is now 9pm, and time for some quality time with my hubby. He encourages me to put my laptop down, and to discuss our upcoming vacation plans. My phone beeps once – a client just checking in that he has been experiencing some symptoms while on the job but is doing just fine, will see me in the morning. I settle back into the couch and enjoy the company of my husband and the drama on t.v. Bedtime rolls around, and I fall asleep shortly after my head hits the pillow, content that I’ve achieved balance in my worklife-net day. About the author Audrey Jung is the current President of the International Society for Mental Health Online (ISMHO).



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Cyber Supervision Anne Stokes

At 6.30am, the alarm goes off and I reluctantly roll out of bed. I can work till very late at night if necessary, but whatever time I go to bed, I don’t like mornings. So I try and avoid early synchronous supervision sessions if at all possible as I need a bit of time to ‘warm up’! Sometimes they have to be scheduled then, depending on what part of the world the supervisee is in, but it’s not my first choice. I work face to face (f2f ) as well as online with clients and supervisees, and I can manage seeing clients at 7.45am without problem. So perhaps it’s about concentration; early in the morning online in realtime, my mind wanders in a way it doesn’t later on in the day as I wait for the supervisee to type their thoughts. I don’t find myself ‘wandering’ with a f2f client even at that time of the


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morning. One of the things we need to know about ourselves as supervisors and supervisees is when we can work best! Sometimes I have laughed at myself as I dress, about my choice of clothes for the day. I work mainly on three days a week now, and on those days, I ‘dress for work’ even if all my work will be online. Old habits die hard, and I still find I have work and non-work clothes. How mad is that? It could also be because I enjoy clothes and it gives me an excuse to have different outfits, of course. I do wonder if other online workers still make these types of differentiation between work and non-work time. After talking to my three cats and having breakfast, I settle to work. I’ll read new supervisee emails, and perhaps begin to reply in a draft document.

Or I might read those I wrote the day before, to see if they make sense, or whether I can see anything I have missed. Whenever possible, both with client and supervision emails, I like to apply the 24 hour ‘rule’ – that is, write the response and leave it aside for 24 hours. Then go back and check it. Often I can see different things at that point, or notice dreadful ‘typos’. In between online work, I will be seeing f2f clients and supervisees, talking to trainees in our online training programme, planning online and f2f workshops and training, researching or writing. Because I work from my home, I’ll also be doing the mundane things of putting washing into the machine, perhaps starting to prepare a dish for supper, popping down to the postbox or the village shop, or answering phone messages. I

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A Day in the Life of an Online Supervisor think that’s both the advantage and disadvantage of working from home and online. You can profitably use the ‘gaps’ but you can’t get totally away from domesticity as you might in an office miles from home. In theory, I finish working at about 6.30 in the evening. I try to be disciplined about this, but can find that the only time I can arrange an online meeting with a colleague or a supervisee is during the evening. I don’t think that’s a good habit, and one I would challenge my supervisees on if I found they were doing this regularly! If I lived in a perfect world, I would have a separate laptop for my work and for my personal life, instead of separate areas on the same laptop. That way there would be less temptation to ‘just look and see if……’ about a work issue after I have been responding to my personal

emails, or buying theatre tickets online in the evening. I love supervising online and its flexibility. I live in England, but can continue to work when we are in our French house. It gives me an opportunity to work with people who are also working outside the UK, for whatever

reason. (Some complications there to be sorted before we begin our contract, but that’s for a later column!) Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer, and Director of Online Training Ltd.

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Marketing Toolbox Susan Giurleo

Marketing your Practice Online: The Start-Up Kit You know that if you have an online component of your therapeutic practice online, you will need to market your services online, too. And while the entry costs to marketing on the internet are low and there are many services out there offering to do all your marketing for you, the truth is effective online marketing requires you strategically leverage the online space to pull interested clients into your practice. The tools listed below are the basic platforms you will need to leverage if you hope to grow a practice online. Let’s take one at a time.


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Online Marketing Start-Up Kit (in order of importance) 1. A professional practice website. Every legitimate online business has their very own stand-alone website. Think of your website as your “online office.” It will be the place where people learn about your work, how you can help them and how to contact you. But more important than that, it can be the place where you express your professional identity, offer services and products that will support your clients and it’s where people will pay you. Many therapists use online listing services, but these are not adequate for an online office. Your own site is the only place online where you will be able to fully showcase your services and powerfully leverage the full potential of online marketing. I encourage therapists to have their site professionally designed. A site that looks unpolished looks unprofessional. Remember, people will come to your site and give it 2-5 seconds before they decide to read more or click away. First impressions matter online. 2. A blog (integrated with your website). A blog (or web log) is a great way to write briefly about your treatment specialty area and educate readers about the benefits of psychotherapy and online services. Blogs do wonders to increase your credibility and establish you as an expert in your field. They also serve the dual purpose of always providing fresh content for your website that will position you well for search engine optimization. One blog article a week will do wonders for your online marketing. 3. A free report or e-course. Online marketing starts with giving interested prospects something for free. This is true for any industry. You can offer a free report, a multiple email course, or an audio recording. The topic should be focused on your treatment specialty. People who want access to your course will need to “opt-in”* by giving you their email address. Once they agree that they want your information, an autoresponder can send them the freebie. Which means you will need an…. 4. Autoresponder. An autoresponder is a platform used to send specific email to specific people at specific times. For instance, someone can opt in to an autoresponder for a free report, as outlined above. Once they opt-in their information is contained in a list and you have permission to send them future emails in the form of e-newsletters.

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TILT – Therapeutic Innovations in Light of Technology

Online Marketing Start-Up Kit continued Using the autoresponder you can send them regular follow up e-mail communication weekly, bi-weekly or monthly. The regular follow up is a key for effective online marketing. The most popular and dependable autoresponder out there is Aweber.com. There are several others includeing MailChimp, MyEmma and MadMaggie. 5. An e-newsletter (or e-zine). Once you have your opt-in report and autoresponder, you will need a way to regularly connect with interested potential clients. I’ve found e-zines to be extremely effective for this purpose. Your e-zine can include a short note from you, an article related to your practice specialty and an occasional offer for a service or product you want to sell. The ratio of valuable information to sales pitch should be 90% to 10%, meaning 90% of the e-zine is free, useful information and 10% is a sales offer. Your readers will come to expect your newsletter and look forward to hearing from you. Once they know, like and trust you many will be likely to engage in a working relationship. 6. A Twitter account or Facebook business page. A social media presence will be an important means to drive potential clients to your website. I suggest starting with Twitter OR Facebook since managing both at the same time can be a bit overwhelming (I started with Twitter). Which platform you chose will depend on where your ideal client “hangs out” online. Do some preliminary market research to determine where most of your clients spend their social media time.

In my next “Marketing Toolbox” we will explore how to do the market research necessary to determine where your clients are online and what information they want. This information will allow you to tailor your marketing and service offerings to your clients’ needs ensuring your practice success. 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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* "Opt-in"

is an online marketing term describing the process someone must go through to receive free information on the internet. All autoresponders will give you the HTML code to place an opt-in box on your website, where interested readers put their name and email address. They then receive an email asking them to click a link to get the information they want. This process ensures that no one enters their email address fraudulently. If you offer free reports and utilize email marketing, you must use an opt-in procedure. It’s the law called CAN SPAM and is closely regulated by the FTC.

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NewInnovations Sensitive internet messages should be sent with at least 128-bit SSL encryption. Such encryption would take longer than the age of the universe to break with brute force guessing. You can tell a service uses SSL encryption when the URL in your browser begins with https:// when logging into your account.

Four Tips for Maintaining a Secure Practice Mark Goldenson Although encryption is not a new innovation, it is still a new concept for many people in the helping professions. When mental health providers start an online practice, a common initial concern is security. The ease of sending electronic data worldwide also makes it easier to intercept. Fortunately with simple best practices, electronic data can be secured even better than paper. Here are four tips toward maintaining a secure practice:


Use Encryption

Encryption converts readable text into unreadable text. This is done via algorithms with alphabet soup names like SSL, RSA, and AES.


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Unless your email recipients have setup encryption themselves, they should be required to log in to a secure site to read your messages. It is fine if a service notifies others of new messages via insecure email as long as recipients must log in to a secure site to read the full message. This is how Kaiser Permanente notifies members of doctor messages or lab results.


Use Strong But Memorable Passwords

Strong passwords are at least eight characters, include at least one number, symbol, or capital letter, and avoid the names of loved ones or dictionary words. When Twitter was recently hacked, the admin password was “happiness”, producing a very unhappy security breach. However, a password should also be memorable. Otherwise you may be tempted to write it down or spend more time recovering your password than typing it. One way to remember your password is to use letters from a mnemonic phrase that includes the name of the site.

For example, “GmMaEmFu” comes from “Gmail Makes Email Fun”. This password would be unique to Gmail so even if someone learned your Gmail password, passwords created this way for other sites should be safe.


Don’t Save Your Password In Your Browser


Password Lock Your Computer

Many web browsers try to make your life easier by saving the passwords you type. Do not do this for any secure site. Otherwise a hacker only needs to gain physical access to your computer, which is a reason to…

When I worked at PayPal, a few people left their desk with an unlocked computer, letting anyone nearby gain access. To discourage this, security-minded employees would hunt for unlocked computers and send embarrassing messages from them to the entire company. When I once saw a colleague’s computer unlocked with Outlook open, I sneakily sent a companywide email announcing he would attend work the next day naked. He quickly learned to lock his computer. Remember that no system is perfectly secure. Even the Pentagon has been breached and certainly doctors’ offices have, famously including the psychiatrist’s office of Daniel Ellsberg, leaker of the

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Pentagon Papers. Laws like HIPAA and the HITECH Act just expect reasonable security. A good definition of security is when the cost of accessing information exceeds the information’s value. With tips like the above, you can help ensure hackers will spend their time elsewhere.

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

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TILT – Therapeutic Innovations in Light of Technology

Online Therapy Institute Verification When you see this seal on a website it means Online Therapy Institute has verified this website as compliant with Online Therapy Institute’s Ethical Standards. We will display thumbnails of everyone who has become verified since the last issue.


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Look Who's


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TILT – Therapeutic Innovations in Light of Technology

Books are the quietest and most constant of friends; they are the most accessible and wisest of counselors, and the most patient of teachers. ~Charles W. Eliot

Love For the

Books of


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Online Counselling: A Handbook for Practitioners Gill Jones and Anne Stokes, 2009, Palgrave Macmillan This accessible guide focuses on technological and therapeutic aspects of online work, relevant across all counselling approaches. With practical step-by-step exercises and jargon-free advice, this is an indispensable tool for all practitioners and trainees planning to work online. Contents include: • Introduction to Online Counselling • Making a start, contracts and boundaries • Counselling asynchronously and synchronously • Using text, image and sound • Useful theories and supervision online • Codes of practice relating to online therapy "What a delightful read! Jones and Stokes have succeeded in covering a tremendous Gill Jones and Anne Stokes are co-directors of range of issues and strategies relevant to Counselling Online Ltd, where they write and all aspects of online communication.’ direct training courses for qualified counsellors and ~Dr Michael Fenichel psychotherapists. They are both qualified counsellors, Past President and Fellow supervisors and trainers, and have also worked in of the International Society universities and further education institutions. for Mental Health Online http://www.onlinetrainingforcounsellors.co.uk

Psychological Aspects of Cyberspace: Theory, Research, Applications Azy Barak (editor), 2008, Cambridge University Press Hundreds of millions of people across the world use the Internet every day. Its functions vary, from shopping and banking to chatting and dating. From a psychological perspective, the Internet has become a major vehicle for interpersonal communication that can significantly affect people's decisions, behaviors, attitudes and emotions. Moreover, its existence has created a virtual social environment in which people can meet, negotiate, collaborate and exchange goods and information. Cyberspace is not just a technical device but a phenomenon which has reduced the world to a proverbial global village, fostering collaborations and international cooperations; thus reducing the barriers of geographical distance and indigenous cultures. Azy "...provides researchers and students with a Barak and a team of prominent social scientists review rich and diverse set of concepts to study as a decade of scientific investigations into the social, they explore the psychological aspects of behavioral and psychological aspects of cyberspace, this new reality." collating state-of-the-art knowledge in each area. Together they develop emerging conceptualizations ~Matthew G. Hile and envisage directions and applications for future PsycCRITIQUES research.

Visit the Online Therapy Institute’s Book Store to purchase featured books and more! http://www.onlinetherapyinstitute.com/bookstore/







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Online Therapy Institute, Inc. P.O. Box 392 Highlands, NJ 07732 877.773 5591 www.OnlineTherapyMagazine.com Magazine Designed by AI Virtual Solutions

In our November issue... 99 Peter Strong writes on working with Mindfulness-based Online Therapy 99 Alisa Clark tells of her experience of therapeutic spiritual autobiography online 99 Stephen Goss discusses research on the number of people who would want to live entirely in a virtual reality 99 A Day in the Life of Geoff Cox - online therapist in the Midlands, UK 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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