TILT Magazine Issue 5

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Issue Five May 2011

Saving the Game: The Use of Gaming within Psychotherapy PAGE 24


Experiencing Presence Some Thoughts


Cutting Edge Technology to Aid People with Mental Health Issues


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 5, May 2011 TILT Magazine Staff Managing Editors Kate Anthony & DeeAnna Merz Nagel Magazine Production Coordinator Agnes Ikotun Magazine Design and Layout Delaine Ulmer 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 Associate Editor for Coaching Lyle Labardee 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.

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Features 9 Experiencing Presence Some Thoughts

24 Saving the Game:

The Use of Gaming within Psychotherapy

40 Cutting Edge Technology to Aid People with Mental Health Issues

Issue in every

6 News from the CyberStreet 14 Research Review 19 Dilemma: Reader Responses 22 What Would You Do?! 23 Wounded Genius 34 Reel Culture 36 Legal Briefs 38 Technology Enhanced Coaching 45 A Day in the Life: Therapist 48 A Day in the Life: Coach 52 CyberSupervision 56 New Innovations 60 Marketing Toolbox 62 Get Verified! 63 OTI Open Office Hours 64 For the Love of Books 66 Advertiser’s CyberMarket

A Note From the Managing Editors… Welcome, or welcome back, to TILT – Therapeutic Innovations in Light of Technology. Our feature article this issue considers the role of gaming in our clients’ lives and the links that gaming has with psychotherapy and counselling. Whether you are a gamer yourself, or know of friends or relatives who play video games, it is likely that you have come across at least some of the media coverage of the “perils” of playing games such as World of Warcraft avidly, and the addictive nature of them. Mike Langlois discusses the positive side of gaming and virtual reality as a metaphor for life itself, and how “there is a world of real feelings in those virtual worlds, and we psychotherapists need to pay attention to them”. Mike’s own blog at www.gamertherapist.com has a gaming element to it, where one can score experience points for “checking in”, sharing links on sites such as Twitter and Facebook, and earn badges for using the Web 2.0 facilities available. We also have a personal understanding of the concept of “presence”, as experienced by Joy Waddington. Joy was moved to write having considered the articles in Issue Three of TILT, and we welcome her personal considerations on the differing levels that the concept of presence can operate on. David Haniff gives us an overview of cutting edge technology and its use in aiding people with mental health issues. He also flags up the importance of the need for large scale research programs to assess the impact of services delivered electronically to those who are receptive to using technology. Our aim continues, issue by issue, to keep you up-to-date with developments in innovations in service delivery; publish interesting articles; provide resources; and feature members and friends of the Online Therapy Institute and the Online Coach Institute. All our other regular columnists are here, with useful and entertaining comment on online supervision, marketing; coaching; research; film culture; legalities; and new innovations. We also have our member’s responses to our last Ethical Dilemma, and a new one for you to consider and to post responses at our social network forums for publication in Issue Six. Our featured “Day in Life” therapist and coach are Kate Scahill and Lori Boxer – we hope you find it as interesting to hear about their work as we do. Also, our resident cartoonist, Wounded Genius, has given us another brilliant take on therapy to make you laugh along the way. If you haven't visited our Linkedin Group, we recommend dropping by! Many dynamic conversations are going on from how to begin offering online therapy, to whether or not virtual world experiences are "real"! We hope you enjoy our fifth issue, whatever professional world you inhabit. All feedback is heartily welcomed at the OTI/OCI social network!

Managing Editors

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TILT – Therapeutic Innovations in Light of Technology

NEWS from the

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

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


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Blog and forum News… Here is a glimpse of what is going on. get a taster and then head to www.onlinetherapyinstituteblog. com, the member blogs at www.onlinetherapysocialnetwork.com, and the OTI forums on the homepage of the Social Network! At the OTI blog, you can click to read an interview with Kate and DeeAnna that was recently published in the British Association for Counselling and Psychotherapy (BACP)’s Workplace Division’s Journal. DeeAnna also shared many useful resources that came from a presentation on the topic of the future of online therapy she gave at the Psychotherapy Networker Symposium. You can read a write up of that Symposium, and also one of the recent OCTIA conference (Online Counselling and Therapy in Action) held in Bristol in March, at which Kate presented the same material almost simultaneously on the other side of the world! At the member blogs, there are posts about spiritual autobiography, counseling in Second Life, myths about telephone counselling, and updates on the state of therapist regulation in the UK. We are pleased to have over 900 members of the social network now, and look forward to hearing more from everyone via the blog and forum features.

Member news… In an experimental form, Olusegun Adebowale has commenced the establishment of online guidance and counselling services for his university. Specifically, prestigious Nigerian Obafemi Awolowo University has established (as a Ph.D. project and thesis) a free online guidance and counselling service for students. This will enable full-time students as well as distance learning students to have unrestricted access to counselling services at any time of the day and from anywhere the Internet is accessible. For more information, visit www. oauonlinecounselling.org.

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TILT – Therapeutic Innovations in Light of Technology

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

Dave Haniff tells us that The Pervasive Technology Lab (CIC) has had a Work In Progress accepted for COMET 2011 (Ninth Interdisciplinary Conference in relation to Communication, Medicine and Ethics) at the University of Nottingham, UK from Thursday 30 June to Saturday 2 July 2011 on a 'A Serious Game to Aid People with Depression'. In addition, a chapter on 'Usability Engineering and E-Health' has been included in Human-Centered Design of E-Health Technologies: Concepts, Methods and Applications (2011), Editor(s): Martina Ziefle (Ed.) Carsten Röcker (Ed.), pp. 41-64, ISBN: 1-60960177-7. The chapter examines user-centred design of E-Health systems including those for mental health applications. Jamie Stacks presented “Mobile Mental Health and Behavior Change- Reaching People Where They Are” at the Arkansas Mental Health Counselor’s Association Spring 2011 Conference. The presentation discussed mobile mental health


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modes and other innovative ways of reaching people where they are. Delegates took a few hours to explore the topic and look at the possibilities the concept gives us to help more people. The presentation encouraged interaction and brainstorming innovative ideas together, was well attended, and had a great group of participants that were full of questions. Marty Jencius tells us about the 3rd Virtual Conference on Counseling, which will be held on September 14-17, 2011 at the CESL conference centre in Second Life (a virtual environment). His Call for Papers is open to any and all topics having to do with counseling or counselor training; topics do not need to be about technology and counseling (although these are welcome). For full details on the conference and how to submit your proposal please visit http://miniurl.org/3VCC .


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BY Joy Waddington

Experiencing Presence Some Thoughts I had a strange experience when I was reading issue 3 of TILT Magazine. Not just the usual “oh that’s interesting”, but a cascade of related responses, each one adding to the previous one as I read through the pieces. The authors in question and the phrases in their pieces were: Paul Silverman – Navigating Conflicts by Email: “Email communicates words and words only” Jean-Anne Sutherland – Reel Culture: “What is ‘real’ to one individual or group may indeed appear crazy to another’ Ralph Friesen – A Day in the Life of an Online Therapist: Recognising ‘presence’ of each other in their written words: “…and in this experience of mutual presence – which sometimes seems to create a Presence with a capital ‘p’…”

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TILT – Therapeutic Innovations in Light of Technology

My first response was my disagreement with Paul Silverman’s statement that email communicates words and words only. I was still pondering why I disagreed with this as I kept on reading through the magazine. I was thinking about ‘energy’ and how directed thoughts and words carry power. I was wondering how well this belief would go down amongst the online counselling community when I read JeanAnne Sutherland’s phrase and realised she had put my thought on the page. My beliefs, whilst real to me, may indeed seem crazy to others. As I realised that my own thoughts were focussing on my experience of ‘presence’ online, I read Ralph Friesen’s piece and there again, he had put my thoughts on the page when he described his experience of mutual presence between client and counsellor seeming to create “Presence with a capital ‘p’”. So if emails communicate words only, how can we possibly experience ‘presence’ and then ‘Presence’, online? As a counsellor new to online work, my own experience of presence online came very powerfully one evening having just sent off a reply to an email client I had been working with


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for a few weeks involving one email exchange per week. I had such a strong sense of this person, not just in the way they had described themselves to me but fully, almost physically, as if we had just been in the room together working faceto-face. At this moment, doubts I had had about the value and authenticity of online counselling were completely dispelled. Through my experience of presence, I had experienced the clientcounsellor relationship and realised that this could be as powerful and therapeutic as face-to-face. I’m writing here about my experience rather than theory but I see presence as operating at different levels: • Having an online presence; for example having a website or Facebook page. Being known about or seen but with no interaction. • Experiencing the sense of someone you have met as having ‘presence’. You remember them for some reason. They have had an impact on you. This is presence seen and felt. • Presence as an instinctual ‘gut’ feeling; for example, knowing that you are being watched by another being (animal or human). This

is presence unseen but strongly felt, at more of a distance but with awareness that someone is focussed on you. At one level ‘presence’ is clearly visible but not felt, at another level, not at all visible but strongly felt. The latter can happen when two or more people are deliberately tuned into each other (not necessarily at the same time) and have a connection - in this case, their writing, which is deliberately written and sent specifically to each other. It is thought and feeling coupled with intention, focussed like a beam towards another person which carries presence through the written words. Here, presence is energy around

and attached to the words. The words carry presence across time and space, between computers and people. Words are thoughts (energy) given form and purpose. Through this they crystallise presence. This beam of presence can also carry the very essence of the sender and whether their words were written simply as the ‘right thing to say’ or with true feeling. What is then transmitted with this writing becomes much more than the words. I think this is one reason why words and phrases can be ‘misinterpreted’ by the recipient of them; not only are they reading them within their own context of beliefs and life experience but the words come wrapped in the ‘energetic state’ of the

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counsellor and whether they were written from the heart. This becomes particularly important in exactly the situations that Paul Silverman is describing during times of conflict, when there may be strong emotions being felt. Whilst the recipient of the email may not see the physical body language of the sender, they will receive the energetic expression of their emotion being felt through the words if this has not been dealt with in some way before writing.


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Presence, like other qualities necessary for creating a therapeutic relationship, is hard to define and to describe. It is a feeling sense and cannot be directly taught (except in terms of focussing the senses on the ‘here and now’) but it is recognised as soon as it is experienced.

Here I have tried to describe my own experience of presence online, and my beliefs that our words carry much more than a simple expression of language when they are focussed and targeted to a known or named person.

About the author Joy Waddington is a counsellor who was, until recently, working for a small UK company supporting people who have experienced trauma. She is currently in the process of developing her own online and face to face work using Therapeutic Writing and Journal Therapy. She lives in North Yorkshire, England.

Online Therapy Institute is proud to announce

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online workshop modules! We offer several modules comprising 5-10 clock hours of learning on many topics! Introduction to Cyberspace: A Primer for Helping Professionals Relationships in Cyberspace: An Introduction for Helping Professionals The Online Therapeutic Relationship: Theoretical Considerations Ethical Considerations of Online Therapy Working Therapeutically Using Asynchronous Email Working Therapeutically Using Synchronous Chat Working Therapeutically Using Telephone and Audio Using Video Conferencing to Conduct Online Therapy E-Therapy: Asynchronous Email/Web Board Therapy, Cyber-culture, Ethics

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TILT – Therapeutic Innovations in Light of Technology

Research Review

Could the Internet save

through improved mental h that there is similar relative expenditure in other countries – and consequent potential cost-savings to be had.

In the USA in 2009 what was known as the “American Recovery and Reinvestment Act” directed more than $US7 billion to make broadband Internet more widely available and used. The elderly were a particularly targeted population, as a group among whom use of broadband Internet remained fairly low in comparison with other groups. George and Sherry Ford (Ford and Ford, 2009) studied more than 7,000 American elderly people to evaluate the impact that the Internet had on their mental health. Mental well-being was measured with an eight-point depression scale, the results being subjected to a battery of statistical tests. Their findings suggest that Internet use can positively affect the mental well-being of elderly Americans, suggesting that it leads to an approximate 20% reduction in depression. This finding has some remarkable implications. Ford and Ford report that “as depression is estimated to cost the United States about $100 billion annually, expanding Internet use among the elderly may have significant economic payoffs” (Ford and Ford, 2009, p.1). It is notable


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In the UK, for example, depression costs £887million, higher than the costs of treating hyper-tension or diabetes. The World Health Organisation reports that depression affects 121 million households around the world, it being among the leading causes of disability and the 4th most costly disease (WHO, 2010). Combined with costs of depression, reported by Luppa et al in 2006, of $US1000 to $US3700 per case this suggests a global cost of depression between a staggering $US121billion and $US4.4trillion, even at 2006 prices. Furthermore, we should note that less than 25% of depression sufferers have access to effective treatments, falling to less than 10% in some countries (WHO, 2010). If the findings of the Ford and Ford (2009) study were replicated among other sectors of the population, some might speculate that this suggests a potential for the Internet to slash 20% of the costs of care for depressed people, perhaps especially among the elderly. That would put the potential net impact of the Internet at a figure approaching $US900 billion. When we put together the trend of

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S t e p h e n G o ss

e $US900billion

health around the world? increasing Internet access around the globe, Ford and Ford’s findings regarding the positive impact Internet use has on mental health and the additional impact provision of therapy for a range of conditions might be expected to have, development of ever more effective online treatments combined with the worldwide reach of online therapists, it is easy to see how more and more people will be able to find relief through online counselling and psychotherapy. Who understands the need for encryption? On a different, more cautious note, the safety of conducting therapy over the Internet has been highlighted once again by a major UK based survey conducted for the Information Commissioner’s Office (ICO - the UK lead body responsible for data protection) (YouGov, 2011). The key finding, from a weighted sample (adjusted to be representative of the population as a whole) of 1998 British adults, was that 40% of home Wi-Fi users are unaware of how to operate even fairly basic privacy and security settings or procedures to protect information. The survey was carried out by YouGov, a respected independent research company, and only included people who could respond online – a sample who by definition will have

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TILT – Therapeutic Innovations in Light of Technology

some technical competence (YouGov, 2011). Up to 16% of respondents used completely unencrypted Wi-Fi access, or didn’t know, meaning that any data sent could, potentially, be intercepted by a third party. The ICO is, understandably, calling for equipment suppliers and Internet Service Providers to make security settings “clear to the end user and fully explain the risks of people using an unsecured connection” (ICO, 2011a, p. 1) so that the need for encryption becomes easier to understand. As commentators on the topic we should, of course, add that Internet therapy providers should pay special attention too and heed the obvious need to educate clients and ensure that they are competent in managing the level of risk and exposure. Professor Tim Bond of the University of Bristol, the UK’s leading expert on ethical practice in counselling, confirmed that encryption should be part of routine practice for counsellors and psychotherapists under the heading of taking ‘reasonable precautions’ to protect sensitive client information (Bond, 2011), despite some evidence that this is not universally understood. Steve Wood, Head of Policy at the ICO said, “People wouldn’t go out and leave their front door unlocked, but many are still surfing the Internet without adequate protection for their personal information … Leaving your Wi-Fi connection unsecured allows people easy access to your network”. ICO have issued new guidance for those concerned to prevent loss of sensitive data (ICO, 2011b). n


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Bond, T. (2011) Personal Communication. Ford, G.S. and Ford, S.G. (2009) Internet Use and Depression Among the Elderly. Phoenix Center for Advanced Legal and Economic Public Policy Paper No. 38. [online] Available at: http://ssrn. com/abstract=1494430 Luppa, M., Heinrich, S., Angermever, M.C., Konig, H.-H. and Riedel-Heller, S.G. (2006) Cost-ofillness studies of depression: A systematic review. Journal of Affective Disorders. 98(1), 29-43. WHO (2010) Depression. [online]. Available at: http://www.who.int/mental_health/management/depression/definition/en/index.html ICO (2011a) Data Protection. [online] Available at: http://www.ico.gov.uk/about_us/research/ data_protection.aspx ICO (2011b) Wi-Fi Security. [online] Available at: http://www.ico.gov.uk/for_the_public/topic_ specific_guides/wifi_security.aspx. YouGov (2011) WiFi settings. Survey by YouGov for ICO. 2nd – 4th March 2011. [online] Available at: http://www.ico.gov.uk/about_us/research/ data_protection.aspx

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 (http://about.me/stephengoss).

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

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Research Call Emerging Technologies & Families Survey (SETF)Š A team of researchers at the University of Deusto in Bilbao, Spain, under the leadership of Dr. Gonzalo Bacigalupe, is studying the impact of information communication technologies (ICTs) on families. The survey is directed to trained family therapists, family psychologists, and family work clinicians in Spain and North America (Canada, US, Mexico). We are interested in learning about your views on the subject of ICTs and families since you have first knowledge of what couple and families are bringing into the therapeutic conversation. This survey has been approved by the Ethics Committee at the University of Deusto. It should take less than 5 minutes to complete. We truly appreciate your participation! Answering the survey indicates that you have read and understood the description of the study and agree to participate. If you wish to participate in a raffle of an IpodTouch, we are asking you to add your email. To preserve the anonymity of participants, the email information will be delinked from the survey data. If you are willing to volunteer for a follow-up interview, please provide your email. For further questions, please contact: Gonzalo Bacigalupe, EdD, MPH. Ikerbasque Research Professor. gonzalo.bacigalupe@deusto. es. University of Deusto, Faculty of Psychology and Education, Aptdo 1, 48080 Bilbao, Spain. Phone/Fax 34.944.139.085


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Check Out the

Online Coach Institute! Resources for Coaches and Helping Professionals!

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Reader Responses


You are a life coach. For years you practiced as a psychologist and now you practice exclusively as a life coach. Your coaching client has tweeted you the following: @lifecoachdiva I am really having a bad day. Depressed. Hopeless. Help me. What Would You Do?!

I would take the conversation offline. If this is a current coaching client then I would have contact information. Getting my client on the phone to determine any safety risk would be my first priority. I am assuming that my psychologist license is up to date and would explain the difference in coaching and therapy to the client. After this has been defined more clearly I would request that we take the relationship out of the coaching arena and put it in the therapy arena.

Reply by

Jamie L. Summers Stacks

I am not sure I would reply as a tweet? But to ask them to privately contact me or a professional for risk assessment. I am licensed, but would never talk about these issues online in view of all. I may have understood this incorrectly. Hopefully, they would have been taught self-care?

Reply by

Kathleen Blumentritt

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Since I do not believe in compartmentalizing my skills (as humanistic therapist and life coach) and believe that the most ethical thing one can do to respond to a client is to help and support in any way possible, I would ask the client what kind of help s/he wants from me, listen to what is going on with him/her, ask whether s/he is feeling suicidal in which case I might suggest that s/he check into the nearest facility, but, short of that, I would coach on the ability to be aware in the present moment and what choices s/he has which might include seeing a psychopharmacologist if the hopeless feeling is not situational but appears to be chronic. I believe that it is unethical to ask a practitioner to pretend they don't have a skill set just because they have chosen to operate more in the coaching domain. I have often found it very useful to have both sets of abilities to really help a client move forward.

I would invite the client to bring the conversation offline and definitely out of the social media sphere. As a psychologist who is now exclusively a coach, I would explain to the client that we can try and assist them using the coaching paradigm, but if difficulties persisted beyond the frame of coaching I could facilitate a referral to a therapist if desired. I would also have a social media policy in place that I share with coaching clients before we started working together, letting them know that I don't interact with private clients in social media to protect their privacy and anonymity.

Reply by

Reply by

Glynis Sherwood

Niela Miller

I would respond via a confidential means (not twitter - I would only use the means of contact my client and I had contracted for if things arise between sessions - probably confidential email). I would express support and my encouragement to raise the issues at our next scheduled session. As a a message like that could (possibly) be an indication of very seriously low mood, I would also ensure that I briefly repeated information I include at contracting about sources of emergency help (such as Samaritans, Befrienders International etc) just in case there is a risk of serious harm or even suicide, given that most suicides happen after the person has given some kind of indication of severe distress, often to a professional and, sadly, too often such hints are not picked up on directly. I would also be raising with my client the appropriateness and risks of contacting me about this kind of thing through twitter, of course. Depending on the nature of our contract I would also be thinking about possible onward referral to therapy, to keep our work focused on the coaching role as, in this instance, my role is clearly as coach not therapist. However, there can (at least sometimes) be a large overlap between therapy and coaching so if it were within both contract and my skill set I would keep working with what the client brings

Reply by 20

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Stephen Goss

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I believe that many issues that might be seen as psychological in nature can be addressed from a coaching perspective since a good coach can use the coaching model to help the client access effective strategies for change. That being said, the above statements "Depressed. Hopeless. Help me." should stand out for any therapist- turned-coach and should take them out of their coaching role for long enough to properly assess risk. Staying in a coaching role for the above would certainly not be advisable. My job would be, at this time, to obtain the support necessary for the client and that would involve getting them connected with the services they need, i.e. Medical, psychological, counseling, etc. Once the situation is stabilized the client can continue with coaching, if desired, but I would most likely talk to the attending professional (with client consent of course) to determine whether the timing is right to return to coaching. I'm embarrassed to say that when I initially read the dilemma I somehow missed the fact that this was a tweet! So yes I completely agree with Glynis (editor’s note: see above) that Step #1 is to take the conversation offline. This is great example of how having a Social Media in place (which I now do) is crucial. The likelihood that such an even would occur is then significantly lessened.

Reply by

Jeffrey Fisher

One issue here is whether the coach still felt competent and interested in introducing psychotherapy into the relationship. Assuming that is the case, I would contact the client and explain that I am a licensed Psychologist (assuming my license is still active) and ask if he or she is interested in bringing psychotherapy into our relationship. I would explain that it would not preclude coaching, but that it does change the nature of our relationship in important ways. I would try to explain the benefits and problems with choosing to do therapy with me as opposed to finding another therapist. Ultimately, I would let the client decide.

I would help. As you said the credentials and experience are there. So there would be no ethical boundary not to. The client already has a bond with you and obviously trusts you and turns to you for help. He or she might not go to another professional to get help from someone else that he or she has no bond with at all. And it would probably be a one off. You don't advertise yourself as a psychologist anymore, so most of your clients will come to you as coaching clients.

Reply by

Mieke Haveman

Longer replies and further discussion are available at http://onlinetherapyinstitute.ning. com/forum/topics/coaches-and-therapistsethical thanks to everyone for their contributions!

Reply by

Tim Desmond T I L T MAGAZ I N E MA y 2 0 1 1


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Hi Eve ry o n e!

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? dilemma You have been seeing your client for a few months and he discusses his blog frequently. You have his explicit permission to view the blog and have done so in the past, both feeling comfortable with the content and the boundaries surrounding discussing therapy on it. At the end of the last session, your client seemed uncomfortable, edgy and worried. He states “perhaps you should visit my blog again…” As agreed within the contract, you do so and while nothing your client has said about the therapy may be considered damning or destructive to the relationship and the therapy, you discover that it has been linked to by many mental health sites and gone viral, inviting thousands of comments, many of which are defamatory.

What would you do?! Weigh in at the OTI Social Network’s Discussion Forum! http://onlinetherapyinstitute.ning.com/forum/


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Wounded Genius Welcome to our Resident Cartoonist, Wounded Genius. We discovered WG through Facebook, when our colleague and friend Audrey Jung posted a cartoon on Facebook, and within half an hour we were chuckling away, following on Twitter, and were commenting on the main blog at 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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Saving t

The Use of Gaming w

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the Game

within Psychotherapy

Luke had begun playing World of Warcraft with his then partner and friends about 2 years ago. In the course of that time, Luke and his partner had tried unsuccessfully to adopt a child, which he believes was thwarted by a judge who did not think gay couples should marry. He and his partner saw the legalization of gay marriage and its overturn in his state, CA. His partner had lost his job, and their relationship subsequently deteriorated, ending in divorce. Throughout all of this Luke was able to stay connected and supported by his friends and other members of his guild. He attributes his ability to move on and be ready for the next phase of his life through the enjoyment of WoW and his guilds.

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TILT – Therapeutic Innovations in Light of Technology

Sam credits a video game with saving his life. He was working abroad in Qatar in the Middle East. He told me how he had fallen into a profound loneliness and depression shortly after moving out of the country. His work began to suffer, and he had a hard time dealing with the isolation. All his friends were back in the US, and he had a hard time being in touch with them. He had seriously begun contemplating suicide. Then he remembered that his friends had been pestering him to try this game, World of Warcraft. He had nothing to lose, so he loaded the game onto his computer. He found the game very compelling, and was even happier to discover that he could log on to the same server as his friends at home. They were able to raid and talk together for the next 9 months he was living in the Middle East, and his isolation and suicidality became a thing of the past.

Matt, a young man in the elevator, is wearing his gaming regalia of a Starcraft T-Shirt. “How are you enjoying the convention?” I ask him. He looks glumly at me and points to his badge which said “TEAM 543” on it. “I came in 5th,” he said. “Congratulations,” I said, adding, “5th place isn’t bad.” “5th place you only win $1,000,” he said, “1st is $25,000.” Turns out that Matt has flown across the country to participate in a tournament. So much for gamers as slackers who have no ambition or work ethic, I think. * * * * *


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Millions of people like Matt, Luke and Sam play video games. Many of them are resilient people dealing with some pretty big life problems. They haven’t checked out of reality, instead they lean on the virtual world and the human relatedness they find through it. I have met people willing to strike up a conversation with me as we wait in line at a convention. I have seen fathers and their adolescent sons and daughters spending quality together. In fact I have encountered couples of every configuration and entire families, all spending time together, not avoiding human contact. When psychotherapists begin working with gamers and exploring their in-world experience, it can be a bit overwhelming. There is so much new language and learning when trying to imagine virtual worlds that you’ve never seen. What’s a raid? Why would someone go on quests? And aren’t guilds something that artisans used in the Middle Ages to control the market? I often encourage therapists to take the time to use the free trial membership on WoW or other games in order to become immersed in the virtual world (and hopefully have fun!) for a little while. But one thing that can get overlooked in the exploration of the technology is the exploration of feelings, and one reason that this gets overlooked is because therapists inadvertently trivialize the experience of feelings experienced in-game or in social media. Virtual worlds create real feelings, and we need to remember that when working with gamers. So who are gamers exactly? Many gamers are adolescents; according to the Pew Research Center in 2008 fully 97% of teens

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ages 12-17 play computer, web, portable, or console games. Ninety-nine percent of boys and 94% of girls play, and 50% played as recently as yesterday. But if you are thinking that all gamers are adolescents though, think again. A 2008 report by the Pew Internet and American Life Project found that 53% of American adults play video games as well, a fight of these almost daily. Of these the majority was the under 30 group at 81%, but all other age groups reported significant numbers from forty-somethings at 60%, baby boomers at 40% and 65 and beyond at 23%.

Nor was there a significant disparity in terms of the racial categories the researchers looked at. 51% of Whites reported playing, 51% of Blacks, and 63% of Hispanics. And in terms of income brackets, more than half of Americans played video games regardless of income. In addition, the more education Americans have the more likely they are to play video games, from 40% with less than a high school degree to 57% with a college degree or more. And whether you live in rural (47%), urban (56%), or suburban (53%) America, there’s a good chance you’re playing video games as well. T I L T MAGAZ I N E MA y 2 0 1 1


TILT – Therapeutic Innovations in Light of Technology

In other words, anyone you meet could be playing video games regularly. These gamers are people, and they have feelings. Even if the stereotypes were true (and they’re not) that all gamers are autistic, people on the spectrum have feelings too. Gamers get excited when they down a boss, upset when someone says something racist in guild chat, and happy when someone whispers them that they did a good job or tells them a joke. There is a world of real feelings in those virtual worlds, and we psychotherapists need to pay attention to them. Do you ask gamers about how they get along with their guildmates as well as their roomates or partners? Do you explore their relationship to their raid leaders as well as their parents and other authority figures? If not, you are missing a whole lot of significant information, and it is only an ask away. Gamers may be reluctant to talk about their in-world feelings and relationships because of past disinterested receptions, but don’t imagine they don’t have them. As if dismissing video games from the therapy office weren’t bad enough, the media regularly hypes scientific research that pathologizes gamers. A recent study in the February 2011 issue of Pediatrics came out reporting that children are using video games “pathologically,” and that this is a global problem. The study reported that out of a sample of 3,034 children, 9% of them could be considered “pathological” in their play, which the researchers found “some serious problems – including depression, anxiety, social phobias and lower school performance – seemed to be outcomes of their pathological play.” A closer look at the study however, could indicate something very different.


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First, there is the problem of cultural translation. The study was conducted in Singapore, and as one of the researchers acknowledges, “In the US, we didn’t follow the kids across time, so we don’t know where that threshold is across each culture or if there is a certain amount that is too much.” And we also don’t know the cultural variables when we compare Singapore, a city-state, with other countries. Children in urban areas often play more video games due to the safety concerns of living in an urban area. But more importantly, let me share with you some other statistics, more close to home. Using a far

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greater sample of over 10,000 teens ages 13-18, the National Institute for Mental Health found that over their lifetimes, 20% of the children had “suffered from a mental disorder with symptoms severe enough to impair their daily lives.” An earlier study with over 3000 younger children found that 13% of the children met the criteria for one or more mental disorder. This figure is actually down from the Joint Commission on the Mental Health of Children, which in 1969 found that 13.6% of all children had “emotional disturbance.” That’s long before the first video game came out. If anything the numbers have gone down with the advent of better treatment, and I might add, the advent of video games. So yes, close to 100% of children in the U.S. play video games, and yes, somewhere between 1320% of U.S. children have some mental health issue, but that’s because the statistic correlates to a pretty consistent percentage of the population over time predating video games entirely. And even if the first study from Singapore were comparable, we could make the argument that kids in Singapore play even more video games and have even less mental health issues than kids in the U.S. The stigmatizing of gamers leans upon the stigmatization of mental illness, which can be challenging, heartbreaking, costly and different from a societal norm, but it is not bad. Mental illness is a prevalent health condition, like other prevalent health conditions such as, per the CDC statistics, Diabetes (10.1%,)High Cholesterol (15.6%,) Hypertension (30.5%,) and Low Back Pain (25.6%.) Gamers and people with mental illness do have something in common: they are

both marginalized and socially stigmatized by the larger population. Like the historical stigmatization of psychosis, today’s therapists often talk about a video gameplaying patient’s reality testing, and their ability to participate in real life. Real life, like many abstract concepts, is often misused. I often hear therapists describe gamers as people who are trying to avoid “real life” by using games. The implicit judgment in this statement is that games are not a part of reality, and therefore are less than. But this seems like a false dichotomy to me; in many ways similar to the way therapists often talk about how therapy is not real life. Of course it is! Therapy has distinct rules and boundaries, and it is a rarified form of relationship, but it is not of a different substance than that of “real life.” If it were truly a different thing, it is unlikely that patients would gain anything useful from it. By the same token, games are part of real life. World of Warcraft is inherently social, there are over 12 million real people playing it all over the world. Gamers deploy real skills to solve real problems and their neurological responses to an “Epic Win” or “Fail” are real physiological responses. This is not to say that the gaming part of a patient’s real life can’t get out of balance with other parts. But it is not a given, and it is not different from the way others use their ego defenses. We all use repression and sublimation to cope with the conflicts and anxiety that occur in daily life. I recall a clinical professor of mine who sublimated her murderous impulses by reading murder mysteries. Hurling fireballs in WoW is an excellent way to prevent oneself from

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TILT – Therapeutic Innovations in Light of Technology

hurling objects or insults in real life. The defenses are there for a reason, and they are not inherently bad. If you are a therapist and you are seeing your patient who games as someone who is not paying attention to their “real life,” ask yourself if you are not perhaps projecting. Many therapists have a great deal of difficulty finding balance in their own lives. They may find it easier to say that a gamer needs to “get a life,” than to realize that they are projecting their own feelings of disregard for themselves onto gamers. By this I mean that therapists often overvalue the work they do in proportion to their family, friends, and other areas of their lives. For example therapists often will see too many patients at a sliding scale fee while their children are impacted by their lower income. They overvalue their therapist role and their parental role suffers. Other therapists may have a difficult time making time for friends or having conversations that go beyond 45 minutes; they may listen but not share of themselves. And still other therapists may neglect exercise and meditation because they don’t have the time, but overbook their work schedules. Before we can help gamers appreciate the need for balance in their lives, we need to empathize with what they are doing. They are relying on the areas of strength they have in themselves when they game, and are reluctant to go to the areas that need development. So let’s be careful if we have to use the idea of “real life” at all. It is often a veiled judgment, and veiled judgments are often projections. Let’s go with Wittgenstein here, who began his Tractatus Philosophicus by stating “The world is everything that is the case.” Privileging


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some aspects of life over others is often the first step towards the oppression of others, be it race, gender, orientation, class, or I would suggest, gaming. And it certainly won’t help our patients get any better. Hopefully the case has been made to investigate the personal realities of people who use video games in non-stigmatizing ways, to explore rather than pathologize. But should we stop here or take the next step? Having begun to see how therapy can help gamers have better lives, what if we dare to ask the question “Can understanding video games make better therapy?” * * * * * In the 19th century Sigmund Freud revolutionized the fields of neurology and psychiatry. Whether you agree or disagree with the particulars, psychoanalytic theory, and the psychodynamic theories that sprang from it changed the way we understand the human mind. Freud pioneered our understanding of the psychosomatic illness, conflicts, drives and the unconscious, to name but a few of the ideas that still influence theory and practice of psychotherapy today. The way Freud came to understand and then attempt to help us understand these ideas was by applying other theoretical models to our psychology. The industrial revolution, with its steam-powered hydraulics and locomotives powered by internal pressure, heavily influenced his beginning work of trauma affect and drive theories. His famous topographic model of the psyche, with its strata of conscious, preconscious and Unconscious, was inspired by the advances in

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Gamification is the act of using the elements of video game design and applying it to other parts of human existence. We have seen gamification begin to be used in businesses like IBM and written about in the Harvard Business Review. MacDonald’s has been using gamification with its’ Monopoly game for years. The Army has been using video game technology to gamify our defenses. Socially Serious Games like Against All Odds are being used to educate people about human rights and global conflict. So can gamification be applied to psychotherapy? I think so.

geology and archaeology of his day. In short, the technological advances of his time informed and shaped the way he thought about and worked with people. Now we are in the 21st century, which is new enough that saying it still fills us with amazement. The revolutions in technology continue, and I want to begin applying some of these technological advances to my theory and practice. I have blogged a lot about games, and today I want to discuss the application of game theory in understanding the human psychology.

In her new book Reality Is Broken, Jane MacGonigal reminds us of the concise yet brilliant description of what a game is according to Bernard Suits. Suits defines playing a game as “the voluntary attempt to overcome unnecessary obstacles.” An example of would be chess where we agree to use the playing pieces on the board, the unnecessary obstacle is that each type of piece can only move a certain prescribed way, and we attempt to overcome this in order to capture the king of our opponent. One example of gamifying psychotherapy is if we posit something similar: Psychotherapy is the voluntary attempt to overcome unnecessary obstacles. Psychotherapy must be voluntary to be successful. If the patient refuses to engage in the process either by physically or mentally absenting himself, therapy will not happen. Yet even people mandated to treatment can benefit from it if they agree subconsciously to engage with us. Adolescents who are dragged to treatment will sit

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TILT – Therapeutic Innovations in Light of Technology

with us in stony silence week after week because they are not there voluntarily. Sometimes we can get a part of them to come out and “play,” i.e. engage with us. And if we don’t want to work with the patient for some reason, it makes treatment next to impossible. Patients come to us because they are attempting to overcome something. They don’t just drop in because they wanted to read the magazines in the waiting room. Something in their life has caused them pain, sadness, anger, discomfort and they want that to stop. They may have noticed a pattern of bad relationships, they may be having traumatic flashbacks, they may be encopretic. But something in their life outside the therapy office has seemed insurmountable, and they want our help in overcoming it. Which brings us to the unnecessary obstacle. I would suggest that in many cases the symptom is the unnecessary obstacle. Whatever the behavior might have been in the past it is no longer necessary now. As a child, hiding their body or mind may have been necessary to keep themselves safe from an abusive parent or sibling. As an adult, their tendency to dissociate in meetings and avoid success at work is an unnecessary obstacle. As a teen a patient may try to control an out of control environment in order to feel a sense of self. As an adult they may seek to control their bodies through disordered eating or self-injury for much the same reason. The challenge here is that the patient continues to go through life unconscious of this and acting as if the obstacle was necessary. In a sense they are playing out (albeit very seriously and sometimes fatally) something outside of the playground.


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Johannes Huizinga in his book Homo Ludens referred to the “magic circle” of play, within which the game unfolds. Therapy, with its 45-50 minute hour, office setting and professional boundaries, is such a magic circle. If you don’t take the idea of play seriously, you will probably find this analogy offensive. But in my opinion, play is very serious. In psychotherapy, patient and therapist become earnestly engaged in the immediacy of what happens. People become ghosts of other people, monsters appear, and ancient kingdoms rise up from beneath the waves for a day. I believe that most people who have been in treatment will be able to recall the immersive and powerful experiences they have had there, experiences which have felt tragic and heroic. Hopefully the patient leaves the magic circle having changed, the unnecessary obstacle is overcome, and life gets better. We live, as Freud did, at the threshold between two centuries. We live, as Freud did, in a world story frequently punctuated by war. I imagine that back then things felt as difficult and healing seemed as urgent as it does today. People came to Freud then, and us now, to help them overcome unnecessary obstacles that were ruining their lives. Freud benefited from applying the diverse technologies of hydraulics, geology and archaeology to understand the human condition; and I believe that we can benefit from applying ludology and game theory to the serious business of therapy. Gamification will not be used to “lighten up” treatment but rather deepen it. Patients who play video games may respond better to leveling up than treatment planning, power-ups as opposed to coping strategies. Virtual worlds may serve as

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practice for real ones, just as therapy has served as practice for other relationships. Freud was an Epic Therapist. He researched and synthesized what was going on in the art and science of his day in order to do better treatment. Today’s Epic Therapists will need to do the same, and that means having the courage to play with technology, games and ideas. Our resistance to doing so is an unnecessary obstacle we need to overcome, and our success in achieving this will be an Epic Win for our patients and our profession. ABOUT THE AUTHOR Mike Langlois, MSW, LICSW is an adjunct faculty member of Boston College School for Social Work and a Teaching Associate in Psychiatry at Harvard Medical School. He received his B.A. from Connecticut College in 1991, and his M.S.W from Smith College School for Social Work in 1994. He has 15 years of experience counseling adults and families. He is the cofounder of Sparta Social Networks and creator of http://gamertherapist.com . He has a private practice in Cambridge, MA.

TILT Magazine is published bi-monthly by The Online Therapy Institute. Each issue is filled with articles, news, business tips, reader comments, and much more.

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TILT – Therapeutic Innovations in Light of Technology


Jean-Anne Sutherland

Scientology, Psychiatry and the Science of Documentary Making Increasingly academics, social workers and therapists are utilizing film in their work. Here in academia, it is assumed that multiple forms of media will be utilized in the classroom including motion pictures, television, the Internet (YouTube videos), popular music and documentaries. While in the past these media (particularly film) were used as a “substitute,” current scholarship offers a pedagogical process for working with media in the classroom. That is, these days we seldom hear a colleague say “I’m out of town tomorrow so I’m having my TA show a movie.” Instead we are engaged with film-as-data rather than filmas-time-filler. Thus, it is not unusual for an academic department to host a small library of films and documentaries for classroom use. Which films end up in these libraries are a result of intentional selection and random, inexplicable surfacing. In the classroom, use of documentaries (“docs,” as the folk in the film department call them) can be paradoxical. On the one hand, the very style of documentaries leads many viewers to accept the content as “true” and “real.” It looks “true,” after all. It looks objective. Like the news. And, well, we all know that news media is true, real and objective (sarcasm intended). Unlike teaching, with motion


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picture (which, while often taken as factual, most recognize as story telling) it’s trickier to remember that documentaries have an agenda, a point of view. A “good” documentary will withhold declarative images and statements. Rather, these let the audience sift through “evidence” and come to a conclusion. While there is an agenda, there is still a presentation that allows for critical thought. Others specifically spell out their agenda (think Michael Moore). Others don’t spell out their agenda in the least but instead use a variety of film techniques to pitch declaratives and absolutes. Recently I was perusing our department film library, which consists of a handful of popular films but mostly documentaries. My eye was drawn to a dark DVD case, the cover a macabre image of (U.S.) dollar bills rolled up, blood oozing, levitating above the plain, white crosses of a graveyard. “What is THIS?” I said aloud, snatching it from the shelves. The title, in white letters, against a black background, the image of blood trailing: “PSYCHIATRY - An Industry of Death” (2006). Like many docs, the DVD case proclaimed such things as “…lays bare the destruction…,”“Graphic footage…,” “interviews with…experts…” I was a bit intrigued. I am a sociologist after all. Most of us don’t scare easily (at least when it comes to “laying bare” institutional practices). As a good social scientist, I checked to see who produced such a doc. The DVD case said that the producers were “The Citizens Commission on Human Rights.” “Well,” my sociologist voice thought, “that certainly sounds like a fine organization.” Who hates human rights, after all (more sarcasm intended)? But, upon further reading, I saw that the CCHR was

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founded in 1969 by the Church of Scientology. Ah, that explains it. What has not been explained to me is how this doc made its way into our collection. Oftentimes films are requested by faculty and ordered for the department. But in my casual asking-around, no one seemed to recall how we acquired this one. Again, not THAT unusual. We don’t keep a sophisticated record of our DVDs. But, I couldn’t imagine anyone actually ordering and showing this in class unless the purpose was to demonstrate objectivity (specifically: lack thereof ) in reporting data. As I said above, all docs are subjective in that they represent the views of the filmmakers. But this one seemed to me to cross the line into heavy-laden “I’ll do what it takes to scare you into believing me.” Of course I watched it. Who would ever comment on something without having critically analyzed that something? I was scared. I was scared by the horror movie music, the fleeting, hazy imagery, the spliced, erratic voice-overs of newscasts. The images come faster and faster until, DONG, there it is: the imposing, word in bloody font: “Psychiatry.” Many of you will know this DVD all too well. For those of you who are not familiar, the video makes it attack on psychiatry, linking it to everything from school shootings to the Ku Klux Klan. According to one “expert,” as far as psychiatry goes, “Nothing, nothing is being done that is legitimate.” As many critics have noted, the producers take tremendous liberty with world history – apparently unconcerned with employing a fact-checker. It has been critiqued as a form of conspiracy theory on steroids. Of course there are some legitimate items

thrown in: over-medicating is an issue; there were some pretty hideous procedures in the 1700’s and; of course an ice pick through the eyeball would indeed hurt. Thus, a few genuine concerns are tossed in but a critical analysis of psychiatry this is not. After a bit of digging, I ran across some information about the distribution power of the Church of Scientology. In a word: OMG (FYI: OMG has recently been added to the Oxford English Dictionary thus legitimating my use of it). It seems the Scientologists have one of the most prestigious distribution centers in the world. For a visual, check this out: http://www. youtube.com/watch?v=2ujgRFmJjyE. I therefore should not be surprised that their DVD made its way into our department library. Given the proliferation of Scientology’s materials, particularly regarding mental health, it might benefit some of us to learn more about their argument. W. Vaugh McCall (2007) reviewed the writings of L. Ron Hubbard. He argues, “The persistent and effective campaign of the Church against the practices of psychiatry require that all mental health providers gain some understanding on the Church of Scientology’s beliefs as they pertain to mental health and psychological functioning.” Objectivity, after all, implicitly requires knowledge of that which we critique. And, objectivity is science, isn’t it?

REFERENCE McCall, W. Vaughn. 2007. “Psychiatry and Psychology in the Writings of L. Ron Hubbard.” Journal of Religion and Health, 46:3 437-447.

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

Mark-eting Yourself

An interesting consequence of conducting your professional work online is that you soon find yourself needing to adopt a domain name. Although an online counselor might choose something based on his or her name, like wendyjones.com or doctorsmith. com, many online counselors opt for a more creative approach and register domain names that incorporate "etherapy" terms (eshrink, cyberpsych, etc.). Of course, it's only a matter of time before someone else starts using a similar phrase and you start to wonder what kind of legal protection you have for your brand. After all, your competitor might not be as ethical as you are, or your client might be confused and head to someone else's website. Then again, you might find yourself receiving a threatening letter from someone using a similar name demanding that you stop your own use. Naturally, we're talking about trademarks here and in this column I want to give you some basic information on the subject. Note this discussion refers solely to U.S. trademarks and is not a complete statement of the law of trademarks. A trademark is (most typically) a word or logo that a purveyor of goods or services uses to identify its goods and distinguish them from others. Trademarks

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should not be confused with copyrights, which are the exclusive rights afforded to creators of literary, artistic and other works to control the reproduction, display or performance of their works. Nor should trademarks be confused with patents, which are limited-term rights granted by the government to inventors for the exclusive rights in their novel, non-obvious, and useful ideas (when described, reduced to practice, and filed publicly in a particular way with the patent office). Unlike copyrights and patents which have a limited term, trademarks may be enforced indefinitely, so long as the mark continues to be used in commerce. Trademarks can be strong, and subject to great protection from use by others, or weak and entitled to less protection, depending on how distinctive the marks are. Strong trademarks include arbitrary or fanciful marks that have no ordinary connection to the services being offered (e.g., Kodak, Amazon, Apple) and suggestive marks that imply something about the product but don't exactly describe what's being offered (e.g., Fresh Direct, Speedy's). Descriptive marks (e.g., "Burger Shop" for a hamburger vendor) are weak but protectable if they acquire "secondary meaning" (i.e., they become associated with a particular source), but generic marks (which simply identify the product) are unprotectable. A trademark owner may lose the right to use the mark if it becomes generic. As a general rule, owners of marks that are relatively strong or which have acquired secondary meaning can prevent others from using the same or substantially similar mark on similar goods and services where there would be a likelihood of consumer confusion upon encountering the junior (later) user's mark. Courts apply a variety of factors to determine whether there is a likelihood of confusion. Owners of famous marks can even prevent others from using confusingly similar marks where there is no likelihood of confusion under a legal theory called dilution.

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See whether the mark and its variants are being used as URLs;

Use several Internet search engines to see if anyone is using your proposed mark;

Search for the mark in Trademark Electronic Search System (TESS) at the U.S. Patent & Trademark Office (USPTO). http://tess2.uspto. gov/

Once you've decided on a mark that you think is unlikely to be confused with another existing mark, you may decide to register the mark. Note that you don't need to register a trademark with the USPTO to have rights in it. All you need to do is use it in commerce (exactly what that means is beyond the scope of this article). You may choose to let others know you are using your name or phrase or logo as a trademark by adding the ™ symbol near the mark, but that's not strictly necessary. Note that the ® mark indicates that the mark has in fact been registered with the USPTO and you should not use it unless that is the case. Among other benefits, registering the mark puts the world on notice that you have rights in the mark and puts you in a much better position if it ever becomes necessary to file a trademark infringement lawsuit. You can apply to register your mark by yourself, and instructions are available at http://www.uspto. gov/trademarks/teas/tutorial. jsp (as of this writing, the filing fee for a trademark/servicemark is $325 in a given class of goods). However, registering can be more complicated than


Before adopting a trademark for your goods or services--probably around the time you are considering registering a domain name--you will want to investigate http://www.op.nysed.gov/prof/psych/ first whether someone else is using a similar mark. There's no point in investing in developing an online brand only to receive a cease-and-desist letter from a senior user. You can do the basic search on your own:

it seems and you will be best served by consulting with a trademark attorney--which can cost closer to $2,000. An attorney can run a formal trademark search, draft a description of goods and services that will pass USPTO muster and withstand any challenges down the road, and just generally help you to navigate the system. Finally, once you adopt and (if you choose) register a trademark, it's up to you to continue to use the mark and to monitor its use in the marketplace. You can lose your rights in a mark if you let others use or register similar marks without objection. An attorney can help you to maintain and enforce your rights. Establishing an online identity is an important part of connecting with potential clients and making a name for yourself on the Internet. A basic understanding of trademark law can help you take confident strides as you build your online counseling brand.

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

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TILT – Therapeutic Innovations in Light of Technology

L yl e L a b a r d e e

TECHNOLOGY ENHANCED D In my previous column I introduced the term “Technology Enhanced Coaching” (TEC), and reinforced the idea that the importance of establishing what is known as “presence” in coaching calls for augmenting the use of technology and web enabled applications with traditional face-to-face or voice-to-voice support. In this column I will present a TEC resource that is as much about cutting edge web technology as it is about the age old effectiveness of writing and sharing personal thoughts with those whom one trusts. Our featured web application, JournalEngineTM, was developed by Kim Ades, MBA and her team at FOM Inc. in Toronto. Before we take a closer at it, let’s start with a perspective on why a web application that supports journaling and the sharing of one’s journal entries with trusted members of one’s community might be so important to us today. Margaret Wheatley, an organizational psychologist and teacher, has been organizing conversations among people in their local communities in over 30 countries. These conversations inspire local leaders to act, to achieve breakthroughs in understanding, reconciliation, and the formation of action steps. In her 2002 book, Turning To One Another - Simple Conversations to Restore Hope to the Future, Meg writes, "For as long as we've been around as humans, as wandering bands of nomads or cave dwellers, we have sat together and shared experiences. …


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We have never wanted to be alone. But today, we are alone. We are more fragmented and isolated from one another than ever before. ... As the world becomes more complex and fearful, we know we need each other to find our way through the darkness. The yearning for community is worldwide. What can we do to turn to one another?" Well, if the skyrocketing number of Facebook users (now exceeding 600 million) is any indication, what many are doing is turning to the web to share and connect with friends. But is today’s Facebook experience intimate enough to achieve the kind of personal sharing and life changing call-to-action that Meg describes? Kim doesn’t think so. While recognizing the success of Facebook and other social media applications such as LinkedIn and Twitter relative to enabling people to connect, she sees these applications falling far short of providing a private, intimate place where members can interact with a close circle of trusted friends

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ED D COACHING and associates, and perhaps even a coach, about their needs, concerns and interests. If Facebook is the lobby, then JournalEngineTM might be considered the private table setting where a few close associates meet regularly for conversation about what matters most. It provides users with web enabled resources, connectivity to selected friends, and even a coach. It provides a place where one may experience the fruit of core coaching competencies such as trusting relationships, being heard, becoming aware, envisioning new possibilities and designing actions. More specifically, the “Standard Features” list for users includes: Journaling, Homework, Courses, Surveys, Import/Export, Social Networking, Messaging, Goals, Privacy and Search. While all of these features work together, the one that finds its place in the name of the software, “Journaling” stands out, and Kim sees journaling as much more than a writing exercise. It is a “blueprint of a person’s history, mindset and intentions.” Shared online with one’s coach and trusted circle of friends, the journal serves as a kind of quilt that all invited parties touch together; it reflects the uniqueness of its owner, yet its design is also influenced by those invited to touch it with their comments. And like all enriching experiences shared with others, it’s the relationship with others that not only

instructs, but reinforces, encourages growth and invites others to keep coming back together. In Meg’s words, “The simplest way to begin finding each other again is to start talking about what we care about ….we need time to sit together, to listen, to worry and dream together.” Not intended to be used independently of faceto-face or voice-to-voice interaction with a coach, JournalEngineTM supports, reinforces and enhances the coach-client interaction in between regularly scheduled visits. We invite you to learn more about JournalEngineTM by having your own experience with it at the Tap the Potential LLC website at http://community.tapthepotential. com, or by contacting Sabrina Schleicher, PhD, ACC; Community Developer, JournalEngineTM Software at 307-856-4662. We’d love to hear from you. If you know of a great TEC tool or web application that serves to enhance the core coaching competencies let us know, we may showcase it in the next issue.

Lyle Labardee, LPC, DCC, is a distance counseling credentialed, Licensed Professional Counselor specializing in web-enabled coaching. He is co-founder and CEO of LifeOptions Group, Inc., and is based in Michigan, USA.

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Cutting Edge Technology to Aid People with Mental Health Issues BY David Haniff


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ental Health problems worldwide are on the increase, with the World Health Organisation (WHO) estimating that around 450 million people worldwide will suffer from such a problem. Within the United Kingdom 1 in 4 people will suffer from a mental health problem throughout their lives. Illnesses such as depression are even taking over the top spot of illnesses worldwide, even looking to beat cancer as the most prevalent illness. Illnesses such as depression can also have an effect on the body leading to health problems such as obesity, anorexia and addictions (such as alcohol and drugs). There are many mental health problems such as phobias (e.g. fear of spiders), Attention Deficit Hyperactive Disorder (ADHD) (which can be diagnosed in teenagers with low attention spans but can also effect adults) and Schizophrenia (hearing voices or/and seeing non-existent entities). Treatments can range to medication (such as anti-depressants, for example Prozac, which release Serotonin into the brain to help relax it), Cognitive Behavioural Therapy (which uses psychological techniques to change their way of thinking), counselling and/or exercise. In conversations with counsellors working for leading mental health charities ‘Milton Keynes Mind’ and the ‘Milton Keynes Richmond Fellowship’ within the UK in certain cases of depression it can be the case that the reason why they are depressed is because their needs are not being met. Due to their low mood they are not getting enough sleep and a cycle ensures where they are having negative thoughts,

coupled with a low mood and lack of deep sleep they cannot therefore rationalise their situation and think positively about their circumstance. Relaxation and sleep are therefore crucial to thinking clearly about why their mood is low. Technology can be used to aid the treatment of such conditions, for example, Virtual Reality (simulated virtual environments) have been used to provide relaxation, by providing pleasurable surrounding. Virtual Reality has also been used to help treat shyness in males when conversing with attractive females, which I can relate to when I was teenager. Believe it or not with virtual characters such as an attractive female, similar physiological responses are present within the male such as sweating and pupil dilation. Virtual Reality has been used to treat such phobias by exposing people to their fear so often that they become accustomed their phobia that it no longer becomes a problem. This exposure therapy has been used to treat people with a fear of flying, spiders and even storm phobia. There has also been a growth in research into the use of Virtual Reality to help treat people with Post-Traumatic Stress Disorder (PTSD). When some soldiers come back from war and back into civilian life they suffer from PTSD and can have flashbacks, disturbed sleep and hyper-physical arousal (e.g. reaction to loud noises). By gradually exposing the soldiers to a simulated combat scenario the effects of PTSD are reduced as they become accustomed to the combat situation. This form of PTSD treatment has also been successful in the treatment of survivors of 9/11. A female patient suffered

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point of view though, all the studies carried out in the US show promise, many of the studies themselves are lacking in the number of people evaluating the Virtual Reality systems. Computer Games have also been used to help treat adolescents with mental health problems.

from a sense of detachment and hyper-physical arousal since the tragedy of 9/11, however, through exposure therapy she was successfully treated. As computers are becoming more and more powerful Virtual Reality as an option for therapy is becoming viable. Due to the realism of the graphics and in some cases the use of sound the applications require a great deal of computational power. In addition, the cost of Virtual reality headsets are also coming down. The software development tools, however, needs to be more accessible, through their interface and their cost. Most of the research concerning the use of Virtual Reality to help treat mental health problems has been carried out in the United States of America, however, through the studies that have been carried out so far the potential for their use is clear. From a scientific


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The computer games industry is said to be worth 10.5 billion dollars worldwide with games ranging from war games such as ‘Splinter Cell’ to social simulation games like the ‘Populous’. The potential for reaching this market through therapy is great. Computer games are generally fun to play and therefore appeal to teenagers. Work in the US has been carried out where a game has been developed that teaches teenagers in an implicit manner how to deal with their problems, such as setting them goals to achieve and planning how to achieve those goals. By embedding information into the game the teenager learns without knowing that they are being taught something. Teenagers are also less likely to seek treatment from a counsellor as they may not see this as a ‘cool’ thing to do, but a game is different matter. A game has also been developed by employees of NASA to help treat children with Attention Deficit Hyperactive Disorder (ADHD). The game takes EEG readings (electrical activity from the brain) and provides feedback on their level of attention throughout the game. The use of EEG data was coupled with a standard game such Gran Turismo (a driving game). The more the child attended to the game the faster the car went. So they were rewarded for improving their attention levels. The use of EEG was originally used by NASA to improve the levels of attention of pilots on long journeys, however, the researchers could see the potential of the technology to help train ADHD sufferers minds.

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As mentioned earlier, relaxation is key in treating people with depression. We can all become stressed out and not able to relax, it may be due to work or personal circumstances. An Augmented Reality system (superimposing graphical information onto real world images) can be used to help learn how to relax using EEG. For example, an image can be captured on your webcam and picture of a person on your webcam can be annotated with the name of the person shown on your laptop. It’s basically superimposing information on a captured image. If the patient can learn to relax, they can get better sleep and think more clearly about their situation reducing the depression. Problems like depression can also be tackled through the use of games. A computer game can be used to help teach

people with depression what to do if they are confronted with certain situation, giving them options of actions to take. If the patient follows the correct course of action (e.g. go and see their GP as opposed to going to the pub!) then they are awarded points. In addition problems such as Obsessive Compulsive Disorder (OCD) can also be addressed by new technology. OCD can manifest itself in irrational behaviours and routines. We all have our routines like getting up at a certain time in the morning, however, OCD can result in people washing their hands excessively almost to the point of their hands becoming raw or hoarding items. By using VR a system can be developed to habituate them to their problems, for instance, exposing them to dirty hands so that they become used to not washing their hands so often. There might

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also be therapist intervention where a therapist talks through what they are seeing in the virtual environment to try and change the way the patient thinks. The use of new technology therefore has a great deal of potential to help therapists treat their patients. The use of new technology such as AR and VR also allow the patient to learn behaviour in a less formal way. Some people who may be averse to seeking treatment with a therapist may find technology a less intimidating prospect. Despite being a form of illness that is growing worldwide research into treatments has been often neglected as it is an illness that is not readily visible. The use new technology can help in its treatment as has been shown with the use of VR to treat phobias and PTSD. Other new technologies such as the mobile phone (which

are ever becoming more powerful) can be used to provide timely information for those that suffer from mental health problems (i.e. sending automatic alerts to the hospital if they are in distress). Technology can therefore be utilised to the advantage of people that are ill mentally and physically. CONCLUSION New technology such as Serious Games and Virtual Reality are showing promise for the treatment of mental health problems. However, in order to gain further clinical acceptance throughout the world larger scale studies are required. The work thus far has indicated that semi-realistic graphical environments do have a cognitive and physical effect on the patient. In addition, new technologies such as mobile technology also provide opportunities to provide timely information using a discrete and ubiquitous technology. The Internet also provides an anonymous and accessible way to access treatment. Technology does not necessarily have to replace contact with experts such as Clinical Psychologists and Counsellors but can be used as a tool to help treat people who are receptive to the use of such new technologies.

About the Author: Dr David Haniff has worked as a Researcher at the University of Birmingham (UK), Loughborough University (UK) and the Open University (UK). He has published over 20 publications in Journals and International Conferences. In 2009 he founded the 'Pervasive Technology Lab (CIC)' (http://www. pervasive-technology-lab.org) a non-profit company looking into the use of new technology to help people with mental health problems. He is based in Milton Keynes, UK.


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an Online Therapist

A Day in the Life of

A typical day for me involves working both a traditional job, and using my after-hours time for freelance work. Although it requires a lot of organization and flexibility (and coffee), it certainly keeps me motivated and engaged. Currently, I am working in an interim academic position in Rochester, NY while I continue to build experience as a distance career counselor.

Kate Scahill

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Over the past two years, I have been attempting to transition out of employment in college settings to making a living as an independent counselor. The greatest challenge for me has been finding the right balance between financial stability, and much needed freedom from a 9-5 schedule. After a brutal winter in the Northeast and feeling a bit out of balance as I juggle two jobs, I am excited for spring and the possibility of shifting my focus to more independent work and the many rewards it provides. My initial goal when I began a graduate program in Counseling Psychology many years ago was to become self-employed. Like many who choose the counseling profession, I desired independence and a less restrictive work environment. However, during my first graduate internship in a small women’s college, I was introduced to career services, which for me was a new path within the counseling profession. I loved the balance of working with students, alumni and employers while gaining a greater understanding of various companies, industries and career paths. It was during the dot-com boom of the late nineties, and the world of work was changing rapidly. Technology was playing an increasing role in the job search process, and counselors were beginning to understand the need to gain technical skills to keep up with the changes. The days of mailing resumes were ending, and using the web for research and job searching was just beginning. I enjoyed learning and teaching new technologies to clients, along with providing traditional counseling, and found it to be appealing combination of techniques. I had no idea that someday these skills would be a perfect fit for a role as a distance counselor! As I continued in my graduate program, the goal


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of a private practice seemed increasingly out of reach, as we were told of the many difficulties of obtaining licensure, being added to health insurance boards, a glut of counselors in certain areas, and the uncertainty of a consistent income. Thus, over the next 10 years, I continued my work in career services. First as a trailing spouse, and then for various opportunities, I relocated several times. I moved from Boston to Cincinnati, New York, New Orleans, Los Angeles and back to the East Coast. Since every city has a college, and most have career centers, the work was never hard to find. I wanted to experience living in various places until I found the right fit. Although I am still looking for the perfect place for me, I have at least narrowed my search and learned a great deal in the process. Through my many moves, I gained vast skills and knowledge of career counseling students of all degrees and disciplines, and working with employers on recruiting and finding the best-fit candidates. I have counseled MBA candidates, engineering students, nontraditional and liberal arts students and many who are undecided or in career shifts. I interfaced with recruiters in industries including investment banking, accounting, marketing, non-profit, entertainment and everything in between. Because I worked closely with employers, I gained a great deal of insight into interviewing and hiring practices, which I can share with my clients. As my last position as an interim Employer Relations manager at UCLA was coming to a close, I discovered ReadyMinds and contacted them immediately. The opportunity to work as a career advisor over the phone and via email seemed like a perfect fit for my background and interests. After an in-person training and a Distance Counselor Certification, I began my career as a ReadyMinds Career Counselor.

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Now, in addition to my job in academia, I am in independent contractor providing career services to students in all phases of their career. The work is conducted over the phone and by email, but to me is no different than in-person counseling. We can cover all of the same topics as we would in an office setting, with the added benefit of being able to quickly direct the client to resources online. Plus, I am easy to contact via email should the client have questions between or after sessions. Distance counseling for many clients is not only preferable, it is the only way they are able to get services that fit into their schedules. My clients are all over the United States, Canada, and occasionally other countries. This encourages me to learn about the cultures and opportunities of other cities in order to guide my clients. My

frequent moves also help me understand the challenges and opportunities my clients face when deciding on possible relocation. I am thrilled to be able to use my technical skills, counseling abilities and draw on my personal experiences to provide solution-focused career services. Distance counseling has afforded me to the opportunity to continue to be geographically flexible, as I am able to take the work with me wherever I go; I just have to figure out where that will be! About the authoR: Kathryn Scahill, NCC, DCC, is a ReadyMinds Counselor and Trainer. In her roles, she now trains other colleagues in the distance field while staying up to date on a daily basis delivering distance services herself to students on a national level. She is also currently a Counselor and Advisor to students at the Rochester Institute of Technology. She is based in Rochester, New York, USA.

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an Online

A Day in the Life of

Our family-owned weight loss business has been serving the community for almost 30 years. I joined the business in 2001 after spending much of 2000 losing 57 lbs. on this very program----and, of course, my mother was harder on me than she was on any other client. I came to see in 2002, as was the pattern all those years before, that during certain times of the year clients would put their programs on ‘hold’ to accommodate stretches of time when they wouldn’t be able to come in for their multiple private visits per week.


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e Coach Lori Boxer

Snowbirds that spent their winters in Florida, those who were away at summer homes, kids at sleep-away camps, college students living on campuses—all would put their progress on the back burner until they returned home. How silly was that?! So many clients would convince themselves that after weeks or months of private, one-onone, individualized in-office counseling, including personal meal planning, and all the other services we provide, they’d somehow be able to go from that mode to an ontheir-own mode with the same discipline and structure and be accountable to themselves! Naturally, what could happen did in most cases. Most clients returned after a long absence having gained much of the weight they had lost.

The next summer was a testing ground, so to speak, for using technology to NOT let distance get between us and our clients.

We started with those clients who spent their summers away from home. Yes, we knew they wouldn’t be perfect. Yes, we knew they didn’t want to be perfect … summer brings longer daylight, more time outside and away from the more controlled environment of one’s kitchen and one’s own cooking. But, we also knew that to go away for the summer with SOME discipline and accountability would be better than none, and if clients would come back at the end of the summer being the same weight as when they left, well … THAT would be a great point from which to pick up when they came home. We put forth the idea to these clients to work with us longdistance during the summer, and they loved it. We asked them to have access to a bathroom scale; to call in (or email) twice a week on preset days with their morning weights; we asked them to either email or fax their food diaries at least once a week; and we scheduled 10-15 minute phone conversations with them twice a week; and, as always, clients have 24/7 cell phone access to me for those “I’m about to lose it’ moments!

In this way, we stayed on top of them, they knew they were accountable, they stayed more focused while away from their home environments, and, most importantly, they felt good about themselves because, as they told us, they were continuing to ‘work’ on themselves and that alone meant they were moving forward. How wonderful it was for clients to return after the summer, having either stayed virtually the same weight or even losing a few pounds. This was important because after the summer, the fall feeding frenzy of the holidays wasn’t far behind! To come home with a 10 or 15 pound weight gain so close to the difficult challenges the holidays bring, is to make the re-start that much more difficult. Well, the rest is history. That winter, we serviced our snowbirds as well as all the kids going off to college in the same manner we did with our clients in the summer. Slowly, through word-of-mouth referrals from these clients and others, we received inquiries from across the country; and most recently started working with a client in London. The advent of Skype technology allows us to offer that type of interface as well. Whether we're seeing clients in person or over the phone, T I L T MAGAZ I N E MA y 2 0 1 1


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our days begin at 8:30 or 9:00 a.m. and end at about 7:00 or 8:00 p.m. three business days a week. For those phone clients where a different time zone might apply (i.e., London), it is a client's responsibility to schedule with us during our normal business hours; although we will of course accommodate an extenuating circumstance by having one of my staff go to the servicing office as early as 7am. Working with clients by telephone is done only in the offices; I am


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the only one in the business who is accessible to clients 24/7 via my home and cell numbers. Between the faceto-face meetings, scheduled (and oftentimes unscheduled) phone conversations, communications via email (there is always a long, long queue waiting for me when I get home), I would say I devote at least 80 hours a week to my business. Regardless of the habit we want to change, the addiction we want to break, the goal

Lori Boxer is the Director of Weight*No*More Diet Center with offices in New York and New Jersey. Visit them at www. weightnomoredietcenter. com and www.facebook.com/ WeightNoMoreDC.

we want to reach, we all need a partner ‌ to push us from behind, to pull us from the front, to who we are accountable. We are that partner to our clients, and technology helps us to help them.

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Cyber Supervision Anne Stokes

Readers are probably familiar with the Cyclical Model for face-to-face supervision. In this article, after first outlining the model, I'm going to show how it can work online. This is not 'the truth' - simply one version of how it might happen on one day. The model has 5 stages, each with five sub-divisions (not all of which need to be present each time) giving a framework to the supervision process. It is a map, and is flexible, not a rigid structure. In my next column, the third stage will be demonstrated, using material from a live IM session. uContract: the overall agreement for supervision and also the agreement for that session. Its five divisions encompass ground rules,


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boundaries, accountability, expectations and relationship. vFocus: the point of entry into the 'work' - the locus of attention. The sub-divisions here are: issue, objectives, presentation, approach, priorities. wSpace: sometimes termed 'creative play space', this is the heart of supervision. It's about exploration, experimentation, reflection, insight and understanding. The five subdivisions are: collaboration, investigation, challenge, containment, affirmation. Online supervisors need to think about (and practice) ways to encourage creativity in this medium. xBridge: this is what it sounds like - the bridge back

from the supervision process into the counsellor's work. Consolidation, information giving, goal setting, action taking, and client's perspective are the five sub-divisions. yReview: this last stage is both a continuous process and periodic major review. Routinely, in each session, there’s a review of what’s been achieved and what needs to be carried forward. The subdivisions here are: feedback, grounding, evaluation, assessment, re-contracting. llllll

So, here is an example of an online session. jAdele has come to an online chat supervision session with Lisa, and in the first few minutes of the session they

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Using the Page and Wosket (2001) Cyclical Model of Supervision Online (Part One) contract for that session. Adele states that today she would like to bring two clients and asks Lisa to be the one to watch how time is allocated during the session to leave her free to think about her clients (groundrules/ expectations). She also tells Lisa that she has signed up for a short course on Solution Focused Behavioural Therapy (SFBT), as in the last session they had discussed the fact that she was beginning to take EAP clients without having any training to work short term (boundaries/accountability). Lisa asks whether there was anything they needed to come back to from that session as she had wondered if she had appeared rather authoritarian at one point (relationship). kAdele presents her first

online client, outlining the issues as she sees them, and says that she wants to have a clearer sense of how her client relates to people (objective and possibly priority). She says how they have been working together (approach) and recognises that the priority is about how she and the client relate. l In the space, Lisa asks Adele if she has an image of the relationship. She comes up with a metaphor which they expand and explore together (collaboration and investigation). Lisa facilitates Adele as she works with anger she feels towards her client (containment), notices that this has been a theme with several clients recently (challenge), and affirms Adele's awareness

that this is something she may need to explore further in her own therapy as well as here in supervision. mAdele then thinks about the insights into her relationship with this client (consolidation) and Lisa asks if she knows about an article which might also be useful in thinking about it (information giving). Adele decides that she does not want to set any goals or plan any action with this client. Lisa asks if she has any sense of what the client might say if she heard Adele decide that no action was needed. Adele is comfortable that she would agree (client perspective). kThey return to focusing on the second face-to-face client, with Adele outlining

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the priority as being how to address the client's difficulties in regularly attending sessions. She tells Lisa what she has done already in this area (approach). l In the space, Adele decides to 'become' the client and asks Lisa to be her - addressing the issue with her-as-client. Adele experiences huge ambivalence towards Lisa as counsellor, and they explore what might be happening both in the 'here and now' and also in the 'there and then'. m This has helped Adele to have a greater understanding of what might be going on for her client (client perspective) and some sense of how she might take this forward (goals and action).

n As they come towards the end of the session, Lisa feeds back to Adele that she has noticed she is gaining confidence in experimenting online, and Adele agrees that she now feels able to risk trying things out. They are both quiet, not typing for a few moments, reflecting on the session (grounding) and then, as always, they look at what’s been useful and what they might have done differently in the session (evaluation). Adele tells Lisa that as part of her appraisal in the agency where she works online, there has been a suggestion that supervisors should be asked for a report (assessment) and suggests they spend some time in the next session discussing this (re-contracting). After

checking details of the next session, they end. llllll

In the next issue of TILT, I will be showing how the third stage – the space – has been used extremely effectively in reality. Reference: Page, S., and Woskett, V. (2001) Supervising the Counsellor: a cyclical model, 2nd edition. London Routledge

Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer, and Director of online training for counsellors ltd.

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Ne wInnovations Money Matters: the State of Online Therapy Reimbursement in the United States Mark Goldenson When bank robber Willie Sutton was asked why he robbed banks, he famously said, “that’s where the money is.” In health care, the money is in reimbursement. SAMHSA reported that in 2003, Americans received $121 billion in mental health and substance abuse care. Public payers – Medicare, Medicaid, and state and federal sources - covered 61% ($74 billion) of these costs. Private payers covered 26% ($31 billion). Only 13% ($16 billion) of costs were paid outof-pocket. The unfortunate reality in American health care is that new services are driven primarily by reimbursement. In telemedicine, previously major barriers – expensive


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technology, licensing regulations, provider and payer skepticism – are falling. Now the number one issue to resolve is reimbursement. The good news is that reimbursement is growing significantly. The first CPT code for online therapy was issued in 2004, but now CMS has dozens of codes to reimburse telemental health. The American Psychological Association recently published an excellent update on reimbursement. Key findings include: ff Medicare reimburses telehealth on par with faceto-face, but services must be done via real-time audio-video and requires that the patient be at a health facility in a Health Professional Shortage Area or outside a Metropolitan Statistical Area – basically a rural area – though a bill introduced last month by Senator John Thune would allow Medicare to reimburse home health services ff Medicaid reimbursement is decided by the states, and at least thirteen state Medicaid programs reimburse psychologists

ff Private sector payers are required by law to reimburse telehealth in twelve states: California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, and Virginia ff A Michigan State University survey found that 130 private payers are reimbursing telehealth, with Blue Cross/Blue Shield being a leader These are huge developments for online therapy. From my conversations with executives at several major payers, each one is either reimbursing today or considering how they will reimburse soon. Some

are running internal pilots to measure effectiveness, cost reduction, and patient and provider satisfaction. Private payers are also under pressure to comply with two new laws: the Mental Health Parity Act and the new health care reform bill. The latter now

CMS-approved procedures for telemental health Centers for Medicaid and Medicare Services procedure

cpt code


99241 - 99275

Office or other outpatient visits

99201 - 99215

Individual psychotherapy

90804 - 90809

Pharmacologic management


Psychiatric diagnostic interview exam


Neurobehavioral status exam


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Ne wInnovations requires free screenings for alcohol misuse, depression, and tobacco use. With forty million new patients soon gaining health insurance, payers must find affordable Mark Goldenson ways to fund is CEO of care and the Breakthrough.com, internet will be a free virtual a compelling office for online option. counseling.

Editor’s Note Not all mental health disciplines have equitable reimbursement privileges. For instance some insurance programs only allow psychiatrists to bill under certain approved telemental health codes such as 90806. In addition, not all insurance companies recognize the 90804-8 codes as appropriate telemental health codes because the codes specifically describe the services as having occurred “in office.” Be sure to check with the insurance company before billing with a code that infers an in-person encounter, otherwise the billing may be viewed as fraudulent by some companies. Modifiers of these codes are available so be sure to bill utilizing the correct modifier (GT for synchronous audio/video and GQ for asynchronous telecommunication such as reviewing a previously recorded interview). Be clear about how you delivered therapeutic services. Most government and 3rd party insurance will not currently reimburse for GT services.

Additional Resources http://www.tmhguide.org/site/epage/93990_871.htm http://www.mdcbh.org/images/startupmemo10272010.pdf http://www.americantelemed.org/files/public/policy/Medicare_Payment_Of_Services.pdf


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• Goodman, Karen D.—MUSIC THERAPY EDUCATION AND TRAINING: From Theory to Practice. '11, 296 pp. (7 x 10), 3 tables. • Bernet, William—PARENTAL ALIENATION, DSM-5, AND ICD-11. '10, 264 pp. (7 x 10), 15 il., 4 tables, $63.95, hard, $43.95, paper.

• McNiff, Shaun—INTEGRATING THE ARTS IN THERAPY: History, Theory, and Practice. '09, 280 pp. (7 x 10), 60 il., $59.95, hard, $39.95, paper.

• Ensminger, John J.—SERVICE AND THERAPY DOGS IN AMERICAN SOCIETY: Science, Law and the Evolution of Canine Caregivers. '10, 340 pp. (7 x 10), 25 il., 1 table, $69.95, hard, $47.95, paper.

• Richard, Michael A., William G. Emener, & William S. Hutchison, Jr.— EMPLOYEE ASSISTANCE PROG R A M S : Wellness/Enhancement Programming. (4th Ed.) '09, 428 pp. (8 x 10), 8 il., 1 table, $79.95, hard, $57.95, paper. • Thompson, Richard H.— THE HANDBOOK OF CHILD LIFE: A Guide for Pediatric Psychosocial Care. '09, 378 pp. (7 x 10), 5 il., 15 tables, $79.95, hard, $55.95, paper. • Wilkes, Jane K.—THE ROLE OF COMPANION ANIMALS IN COUNSELING AND PSYCHOLOGY: Discovering Their Use in the Therapeutic Process. '09, 168 pp. (7 x 10), 2 tables, $29.95, paper.

NOW AVAILABLE! • Anthony, Kate, DeeAnna Merz Nagel & Stephen Goss — T HE US E OF TECHNOLOGY IN MENTAL HEALTH: Applications, Ethics and Practice. '10, 354 pp. (7 x 10), 6 il., 5 tables, $74.95, hard, $49.95, paper.


• Bellini, James L. & Phillip D. Rumri l l , J r.—R E SEARCH IN REHABILITATION COUNSELING: A Guide to Design, Methodology, and Utilization. (2nd Ed.) '09, 320 pp. (7 x 10) 3 il., 5 tables, $66.95, hard, $46.95, paper.

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• Marvasti, Jamshid A.— PSYCHO-POLITICAL ASPECTS OF SUICIDE WARRIORS,TERRORI S M A N D M A RT Y RDOM: A Critical View from “Both Sides” in Regard to Cause and Cure. '08, 374 pp. (7 x 10), $73.95, hard, $53.95, paper. • Moon, Bruce L.—INTROD U C T I O N TO A RT THERAPY: Faith in the Product. (2nd Ed.) '08, 226 pp. (7 x 10), 20 il., $53.95, hard, $33.95, paper. • Wiseman, Dennis G.— THE AMERICAN FAMILY: Understanding its Changing Dynamics and Place in Society. '08, 172 pp. (7 x 10), 4 tables, $31.95, paper. • France, Kenneth—CRISIS I N T E RV E N T I O N : A Handbook of Immediate Person-to-Person Help. (5th Ed.) '07, 320 pp. (7 x 10), 3 il., $65.95, hard, $45.95, paper. • Martin, E. Davis, Jr.— PRINCIPLES AND PRACTICES OF CASE MANAGEMENT IN REHABILITATION COUNSELING. (2nd Ed.) '07, 380 pp. (7 x 10), 7 i1., 2 tables, $69.95, hard, $49.95, paper. • Perticone, Eugene X.— T H E A RT O F B E I N G BETTER: An Approach to Personal Growth. '07, 268 pp. (7 x 10), $58.95, hard, $38.95, paper. • Palmo, Artis, J., William J. W e i k e l & D a v i d P. Borsos—FOUNDAT I O N S O F M E N TA L H E A LT H C O U N S E LING. (3rd Ed.) '06, 468 pp. (7 x 10), 5 il., 3 tables, $85.95, hard, $61.95, paper. MAIL:

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TILT – Therapeutic Innovations in Light of Technology

Marketing Toolbox Susan Giurleo

How to Leverage Twitter for Online Marketing You probably know Twitter is a microblog that allows you 140 characters to communicate. Initially, this doesn’t seem like enough words to communicate a full thought, never mind share important mental health care information. But if you know a few strategies to leverage the power of Twitter, it can be a wonderful tool to market your services, products and programs. Here are a few ways I’ve been using Twitter to grow my business:


Have a plan. Whether you want to reach potential clients, customers, or colleagues it’s important to know why you are on Twitter. Just like a more traditional marketing approach, you need to know who you are trying to connect with and what message you want them to hear from you.


T I L T MAGAZ I N E MA y 2 0 1 1

Be human and professional. No one builds relationships with a logo or a brand. Use your face as your Twitter avatar. People want to see who they are conversing with. Also, have a human bio that you write in the first person explaining a bit about who you are and what you do. If you’re comfortable, share a piece of personal information on your bio that gives people some insight into your personality.



Listen. When I started using Twitter years ago, I spent a lot of time watching and listening before I ever tweeted my own words. You can listen by following people you know and respect, using Search.Twitter.com and type in a keyword that interests you (this could be your hometown, a treatment word, such as ‘depression,’ or some other interest of yours like ‘gardening.’) When you see who’s talking about what, you can decide

w w w . on l in e t h e r a p y instit u t e . c o m

Susan Giurleo, Ph.D. manages http://drsusangiurleo.com, bringing mental health support to people via social media and online technologies. She is based in Massachusetts, USA. For more information on how to develop such relationships online as discussed, visit her new blog at her website and consider registering for her new report: “7 Steps to Ethical, Effective Health Care Social Media.

who to follow to grow your network. You can also get a good sense of what that particular community is interested in and tailor your business offerings and marketing plan accordingly. Use Twitter to educate, share, teach and inspire. Twitter is at its best when we use it to share information that is useful to our followers. You can tweet a link to an article, research paper, or a resource that might be of interest to your followers. Be generous with retweeting (RT) other’s information. It is fine to share your own information but that should not be the bulk of what you share.


Engage in conversations. Twitter is social. People converse with each other. Conversations can range from, “I like your information. Thanks for sharing,” to more involved reciprocal conversations about a piece of research or current event. I converse most often with colleagues and have very rarely chatted with clients (past or present). One caveat is that therapists should not discuss any treatment related issues in Twitter, whether or not the client’s identity is removed.



Take the conversation off Twitter. When I establish a positive relationship with someone via Twitter, at some point one of us moves it off of Twitter and into a more private fo-

rum. Sometimes this is via a direct message (DM), email or a phone call. This is how working relationships are established, whether with clients or colleagues. Always allow a potential client to reach out to you first. They may ask “How can I schedule an appointment,” and you can refer them to your website, email or direct message them your phone number. It’s not ethical to approach potential clients uninvited. Twitter is a wonderful networking tool when you have a sense of how to use it efficiently. Remember that people use social media to connect and find information. When you are a source of useful information and take the time to join into the conversation people are more likely to want to work with you.

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TILT – Therapeutic Innovations in Light of Technology

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TILT – Therapeutic Innovations in Light of Technology

“You can never get a cup of tea large enough or a book long enough to suit me” ~C.S. Lewis

Love For the

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Cyberpl@y: Communicating Online Brenda Danet (2001)

This book explores playfulness and artfulness in digital writing and communication and answers penetrating questions about this new medium. Under what conditions do old letter writing norms continue to be important, even in email? Digital greetings are changing the way we celebrate special occasions and public holidays, but will they take the place of paper postcards and greeting cards? The author also looks at how artforms, such as virtual theatre, ASCII art, and digital folk art on IRC are flourishing, and how many people collect and display digital fonts on websites, or even design their own. Intended as a “time line” documenting developments online in the mid to late 1990’s, when the Internet became a mass medium, this book treats the computer as an expressive instrument fostering new forms of creativity and popular culture.


Infinite Reality Jim Blascovich and Jeremy Bailenson (2011)

The coming explosion of immersive digital technology, combined with recent progress in unlocking how the mind works, will soon revolutionize our lives in ways only science fiction has imagined. In Infinite Reality, Jeremy Bailenson (Stanford University) and Jim Blascovich (University of California, Santa Barbara)—two of virtual reality's pioneering authorities whose pathbreaking research has mapped how our brain behaves in digital worlds—take us on a mind-bending journey through the virtual universe. Infinite Reality explores what emerging computer technologies and their radical applications will mean for the future of human life and society. Along the way, Bailenson and Blascovich examine the timeless philosophical questions of the self and "reality" that arise through the digital experience; explain how virtual reality's latest and future forms— including immersive video games and social-networking sites—will soon be seamlessly integrated into our lives; show the many surprising practical applications of virtual reality, from education and medicine to sex and warfare; and probe further-off possibilities like "total personality downloads" that would allow your great-great-grandchildren to have a conversation with "you" a century or more after your death.


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