TILT Magazine (Issue 9)

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volume 2, Issue three January 2012

Composing Oneself in E-Counselling PAGE 24

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A Serious Game to Help People with Depression PAGE 40

Practical Magic PAGE 59

Distance Counseling Survey Results PLUS...

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


TILT - Therapeutic Innovations in Light of Technology TILT is the magazine of the Online Therapy Institute, a free publication published four times a year online at www.onlinetherapymagazine.com. ISSN 2156-5619 Volume 2, Issue 3, January 2012 TILT Magazine Staff Managing Editors Kate Anthony & DeeAnna Merz Nagel Magazine Distribution Coordinator Sophia Zollman Magazine Design and Layout Delaine Ulmer Associate Editor for Research Stephen Goss Associate Editor for Innovations Samantha Murphy 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 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 A Serious Game to Help

People with Depression

24 Composing Oneself in E-Counselling

40 Practical Magic 59 Distance Counseling Survey Results


Issue in every

6 News from the CyberStreet 16 Research Review 20 What Would You Do?! 22 Wired to Worry 34 Reel Culture 37 Legal Briefs 38 Technology Enhanced Coaching 51 A Day in the Life: Therapist 56 A Day in the Life: Coach 68 CyberSupervision 70 New Innovations 74 Marketing Toolbox 76 Get Verified! 77 OTI Open Office Hours 78 For the Love of Books 80 Advertiser’s CyberMarket


A Note from the Managing Editors… Welcome, or welcome back, to TILT – Therapeutic Innovations in Light of Technology.

kate anthony

& deeanna merz nagel with the

online therapy institute in second life

This issue, we have two exciting new members of our regular contributor team! A huge welcome to Samantha Murphy who takes over our New Innovation column, and also to Christine Korol who is our new Resident Cartoonist, with her unique take on stress and anxiety, particularly in relation to how technology affects our day-to-day lives.

Our features in this issue include a case-study from Cedric Speyer and Eusebia da Silva considering the importance of composure and process when formulating client emails, with actual case material to illustrate their points. To compliment their article on working with email, we have a great simple and illustrative feature from Kasia Zukowska of Ecrypt, one of our Verified organisations, on encryption. Kasia demystifies encryption, particularly how “every time you connect to a WiFi network and are required to enter a password encryption is at play; every time you access a site that is prefaced with “https” encryption is utilized; and every time you try to back up a CD but can’t it’s because it is encrypted.” She shows us how encryption is nothing to be scared of! The results of the survey Steven Starks has been working on and that was publicised in the last issue of TILT are in! 211 respondents gave us a snapshot of who online practitioners are and how they work, with participants from all over the world. We hope this small informal survey gives everyone a chance to consider their own journey to being an online practitioner, and encourages you to conduct your own research and take part in the important process of discovering as much as we can about our field. Finally, Dave Haniff tells us of his work on a new Serious Game for Depression. You can take part in Dave’s own research (see Research Call) in providing feedback to the game, which aims to show computer games as being an interactive fun and less formal way of learning new material. 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 coaching; research; legalities; film culture; and CyberSupervision. There’s a new Ethical Dilemma for you to consider and to post responses at our social network forums for publication in the fourth issue of Volume 2 (Issue 10). Our featured “Day in Life” therapist and coach are Sana Quijada and Jackie Walker respectively – we hope you find it as interesting to hear about their work as we do. We hope you enjoy this issue, whatever professional world you inhabit J

Managing Editors T I L T M A G A Z I N E Jan u ar y 2 0 1 2


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, www.onlinecoachinstitute.com/blog, the member blogs at www.onlinetherapysocialnetwork.com, and the OTI forums on the homepage of the Social Network! At the OTI and OCI blogs…. Kate blogged about her attendance at the launch night of the new Risk Awareness and Management Programme (RAMP) for Delivering Mental Well-Being Services Online at the New Savoy Partnership Conference in London on the 24th November last year. The Online Therapy Institute was a major contributor to the document, which you can download from the blog here! To complement our feature article on encryption this issue, DeeAnna blogged about how to understand encryption and offers a document written by the American Medical Association to address telehealth and Protected Health Information (PHI). The document also serves as a guide for any person or organisation seeking to encrypt mental health or coaching services. Kate attended the TEDx Holyrood Women event in Edinburgh in December, livestreamed by our colleagues at OnlinEvents. The event aimed to give women the chance to step into a global conversation, and was linked to the same event taking place in New York. The theme, aligned to the main US stage, was “Relationships and the Ties that Bind us”. At the Online Coach Institute blog you can also read about how the Institute is now an International Association of Coaching (IAC) Coaching Masteries™ Authorised Licensee. As part of their own Continuing Education as Coach Educators, Kate and DeeAnna have both successfully completed the first part of the IAC Certification process and submitting their Learning Agreement Proposals for the coming12 months. The masteries are already incorporated in the OCI course “Ethical Issues for Therapist-Coaches”. At the member blogs, Kate wishes OTI member Pandora huge congratulations on her prestigious award of the 2011 Mind Media Award for her blog on living with mental illness. We recommend you pop in

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from time to time to hear the authentic experience of the client side. Alisa E. Clark blogs about the value of journaling to “throw away old junk” and invites fellow members to join the blog with their own experiences of spiritual journaling.

Member news… Dr Arthur S. Trotzky, www.redi-connection.com and www.onlinegrouptherapy.com, has been hired by the Israel Anti-Drug Authority to set up and facilitate online group therapy and support for Israel’s recovering addicts. Israel is now the first country to utilize the internet for providing video and audio support groups on the Internet. The first group has been up and running since December 2011. Bob Rosen says thanks in a big way to DeeAnna and the Institute for Life Coach Training, as well as the wonderful support and on-going communication with the CCE, as he is celebrating having the BCC "shingle" on his wall. “It means a great deal to me.” Says Bob!

17th. As this is a conference about working online the conference will also be accessible online. Wherever you are located in the world you will be able to view the conference presentations live, participate in question times and network with other attendees. John says the fun has started already over at the OCTIA Facebook page where there are video trailers from previous years, a free download of Tim Bonds 2011 presentation "Ethical and Legal Issues for Online Counsellors" and a competition to win Therapy Tales goodies. Congratulations to Stephanie Palin, who was recently elected President of the International Society for Mental Health Online, and to Jay Ostrowski who becomes President-Elect. Other OTI members who remain or have become Members-at-large are Stephanie Williams and Ron Kraus. Lynn Martin becomes Secretary-Treasurer, and Dominik Rosenauer moves into his role as Past-President.

John Wilson formally announces OCTIA 2012, an annual conference about online therapy which is being held in Bristol UK on Saturday March

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

Subscribe Today! 8

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A

Serious Game

to Help People with Depression BY DAVID HANIFF

Depression is on the increase worldwide and World Health Organisation (WHO) have pointed out that it is in the top three illnesses suffered within the population, with over 450 million people worldwide likely to suffer from mental health issues (WHO, 2010). T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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Depression is more than feeling low occasionally, which we all do. Depression is more sustained and can lead to a disruption in a person’s daily life. It can lead to physical as well as mental problems where some people may experience eating disorders, heart problems, addictions (such as drugs and alcohol) as well as feeling suicidal. The illness is therefore an important problem within society which has widespread implications not just for the individual but also for those around them. The Pervasive Technology Lab (CIC), founded in 2009, is looking at the use of new technology to help people with mental health problems such as depression and anxiety. The non-profit organisation is working alongside Milton Keynes Mind, a local mental health charity that has been treating people with mental health problems for over thirty years. A project was formulated in 2009 to create a ‘Serious Game’ to help people with depression, funded by the Big Lottery Fund within the United Kingdom. The term ‘Serious Game’ seems like an oxymoron. However, computer games are increasingly being used to teach serious subjects. There are games that are being used to teach subjects such as auditing and leadership skills. There is also a game called ‘TruSim’ which teaches paramedics how to deal with patients who have been subject to a disaster - a bomb blast, for example. There are many benefits to such an approach to teaching, such as games being a fun and less formal way of learning new material. Computer games are also interactive rather than a passive form of learning as well as being a visually appealing way to take in information. Furthermore, it can be used at anytime from a variety of locations which may suit the lifestyle of some individuals. The first stage of the project to create a computer game to help people with depression was to talk to people within the profession of helping people suffering with the condition. Therefore, two

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focus groups (group interviews) with counsellors and professionals were conducted exploring the idea of Serious Games to help their clients. Milton Keynes Richmond Fellowship and Milton Keynes Mind counsellors and professionals were consulted about the concept of a Serious Game for those with mental health problems as well as gaining an idea of the typical triggers of depression and how some clients can be helped with certain techniques. Within the sessions, it was emphasised that the Serious Game was not intended to replace traditional methods such as talking therapy a n d physical exercise (which releases Serotonin within the brain) but is intended to be used as a tool to help them treat their clients. One size does not fit all and the use of a Serious Game or any sort of technology maybe suited to others but may not be appropriate for some. From the focus groups several triggers of depression were identified, for example, exam pressures, bullying at work and relationship problems. There


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are a number of problems that can lead to depression where there can be a ‘spiral down’ effect where the problem seems insurmountable. The counsellors suggested several ways of dealing with such problems such as breaking down the problem into smaller more manageable components, looking at the root causes of depression and rationalising about the situations, exercising and getting into the open air to help them relax. The physiological implications of emotions such as anxiety which can lead to depression were also discussed. If the brain is overanxious the fight or flight instinct takes over where cortisone level in the brain becomes high (which restricts thinking). The fight or flight reaction in the brain was designed to give quick responses to dangerous situations. However, if it is unnecessarily triggered the ability to think your way out of the situation is restricted. Research with soldiers have suggested that prolonged exposure to ‘Stress Hormones’ produced by the Amygdala (Wingen et al., 2011) in the centre of the brain can lead to long term memory problems and diminished decision making processes. At the opposite

spectrum serotonin relaxes the brain, and can be gained from such sources as sufficient deep sleep, exercise and sunlight as well as positive thoughts. The game itself is intended to help people who potentially can be at risk of being anxious due to certain circumstances and therefore increase their cortisone levels. By providing information about how to deal with difficult situations, it is hoped that the client will be able to rationalise about a similar situation in reality. The computer game presents various situations that could potentially trigger depression and gives the client four options to choose from. Each of these option could be the most appropriate or least appropriate. For instance, if the client has an argument with their partner they could either talk it through with their partner which would be the most appropriate action or avoid the problem and go the bar which would be one of the least appropriate responses to the situation. The client is presented with a happy face with the most appropriate response and a sad face for the least appropriate. The client is also given an explanation as to why they had a happy or sad face. You can see a demonstration here. Example screen shot on the top of page 12.

The full version of the game addresses situations such as exam pressure and conflict at work. In the initial focus group all of the counsellors said they would use such a game in their sessions. The other advantage of the computer game is that it is anonymous which may save some client’s embarrassment if they choose the least appropriate action. Soldiers have been known to be more receptive to using a computer based form of treatment as opposed to seeing a counsellor about Post-Traumatic Stress Disorder (PTSD) as it is less intrusive. The technique of using a game to educate people in how to react to situations is more akin

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example of a serious game for depression

to Cognitive Behavioural Therapy (CBT), where the technique is used to help people change the way they think. This is as opposed to medication such as anti-depressants (for example Prozac) that has often been used to help relieve depression (Selective Serotonin Reuptake Inhibitors (SSRI’s) which relax the mind chemically). The game takes a different approach to depression. The game itself is quick to complete which may suit some patients, and the scores themselves are not recorded to reduce anxiety about performance levels. Computer games have been used by therapists where adolescents are less receptive to one-to-one therapy and prefer to use a computer game. The computer game is set in a detective agency and teaches the gamer to set themselves goals and plan how to achieve those goals (Coyle and Anthony, 2006). A virtual environment in Second Life has also been used to help people with Autism where they can meet other players with the same condition and share experiences and how they overcame them (Chapman, 2011). 12

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A computer game was used to teach children about bacteria including the best way to clean their teeth and the research found a significant difference between the game and conventional methods. Computer games are a part of many young people’s lives as an entertaining pastime and as such seems (Serious Games Institute, 2009) to be an ideal way of imparting knowledge. The computer game market is said to be worth $10.5 billion and the average age of a gamer is increasing to 35 years old. The gender using the games is also changing with 40% of computer games users being female. The use of games is therefore a media that can provide therapy to a wide audience. Although initial reactions to the game are positive, a large scale study is required to evaluate the game in order to gain clinical acceptance as a tool that can be used by clinicians for their clients. Unconventional methods of therapy have been used to help clients, such as Internet based


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systems like ‘Beating the Blues’ for depression and ‘FearFighter’ for anxiety. Virtual Reality has also been used for PTSD and Phobias (Rizzo et al., 2006). With growing capabilities mobile phones also have the potential to offer services to the client, for example, the location of the nearest mental health support facility or provide details of activities to promote mental well being. Mobile technology is becoming ubiquitous within society and can provide timely information at any time and location. Technology can therefore provide an important assistive role to the sufferers of mental health problems. As mentioned it is unlikely to replace people contact but it provides an additional method to aid the client in supporting them and help them on their road to recovery. The potential for technology is great, and there are also other aspects that technology can be used to affect the mood of the client. For instance, a future development for the computer game is to use music to lift the mood of the player. A person’s favourite piece of music can often affect the feeling of an individual - it can stir up memories or due to the song being positive it may invoke the same reaction within the player. Often some types of music are used in conventional games to help induce adrenalin. Calming music often relaxes the mind. There are many other forms of mental health problems that can be tackled using technology. For instance, stress can cause mental and physical problems. From a financial perspective, in the United Kingdom it costs the UK industry £5 billion a year. Technology can be used to provide pleasurable virtual experiences to help relieve the stress, i.e. lying on a beach in Jamaica. Obsessive Compulsive Disorder (OCD) is also a big problem affecting around 10% of the population (National Institute of Mental Health, 2008). Exposure therapy (gradually exposing the client to the problem until it no longer affects them) can be used to present the trigger in a safe, controlled environment.

For example, if the client has a problem with leaving the door open within their home the virtual environment could recreate their house and leave the door open and a therapist could talk them through their feeling about seeing the door open. Technology can therefore be used in conjunction with therapist intervention. The computer game for depression that has been developed is straightforward. However, as mentioned through earlier examples the game’s complexity can increase through adding personalisation (i.e. music), multi-player interactivity, mobile technology and therapist intervention. The company is looking at creating a suite of software applications that can be used by counsellors, clinicians and professionals so that they can choose which are the best options for their client. It may be the case that some clients will not want The technique to use any of using a game technology to educate people whatsoin how to react to ever and therefore situations is more only use akin to Cognitive tradiBehavioural Therapy tional (CBT), where the methods such technique is used as talking to help people therapy change the way and group they think. sessions. In conclusion, the game itself from initial reaction has gained positive feedback. It is a different way of imparting information to people in a fun, informal and anonymous way. A large number of counsellors, clinicians and professionals will need to evaluate T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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it as well as the sufferers of depression. However, technology such as Serious Games, mobile phones, virtual environments and personalisation can provide computer applications that can provide support for those with mental health problems. As well as depression other forms of mental health problems can be addressed such as OCD and phobias. In some cases a big hurdle is the cost of development of complex systems in terms of labour, hardware and programming environments. However, these costs are coming down and the benefits of using technology are becoming apparent. As reiterated several times face-to-face contact with other people whether it is a professional or a fellow sufferer cannot be

replaced. However, technology can act as an extra technique to help the client overcome their problem.

ABOUT THE AUTHOR Dr David Haniff has a degree in Computer Science, an MSc in Cognitive Science and Ph.D in Augmented Reality gained from the University of Birmingham. He has worked at the University of Birmingham, UK, Open University, UK and Loughborough University, UK as a researcher.

REFERENCES Chapman, S. B. (2011) http://www.brainhealth.utdallas.edu/index.php/blog/brainhealth-researchstudying-autism-and-aspergers Mathews, M. Coyle, D & Anthony, K. (2006) ‘Personal Investigator’, in Therapy Today: 17(7) 30 – 33. National Institute of Mental Health. The Numbers Count: Mental Disorders in America. Available at: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml. Accessed January 10, 2008 Rizzo, A; Pair, J; Graap, K; Manson, B; McNerney, P.J; Wiederhold, B; Wiederhold, M; Spira, B (2006). "A Virtual Reality Exposure Therapy Application for Iraq War Military Personnel with Post Traumatic Stress Disorder: From Training to Toy to Treatment". In Roy. M. (ed.). NATO Advanced Research Workshop on Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Washington D.C: IOS Press. pp. 235–250. http://www.macs.hw.ac.uk/modules/F24VS2/Resources/RizzoVirtualRealityExposure2006.pdf. Serious Games Institute – Applied Research Strategy (2010) www.ics.uci.edu/.../SGI_Applied_Research_strategy_2009.doc WHO (2010) Mental Health: Strengthening our response, http://www.who.int/mediacentre/factsheets/fs220/en/index.html Wingen, G, A, Geuze, A, E, Vermetten, G, E and Fernández, G (2011) Perceived threat predicts the neural sequelae of combat stress, Molecular Psychiatry, 16, 664–671.

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Stop by our offices in Second Life ande!

m o h t a lf e s r u o y e k ma

Location address: http://www.onlinetherapyinstitute.com/second-life/

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Research Review

Case Study & Online Th Case studies of one kind of online therapy or another have been vital and influential elements of the research literature for many years. Especially when interventions are new, case study methods offer an especially appropriate means of carrying out research that offers insight into what has been achieved in that specific instance. They do not, of course, tell us about what can be achieved in other cases, and even less so what is likely to be achieved across a broad range of specific instances – both of which require different kinds of outcome research with greater predictive power, like controlled trails – but insofar as a future case has similar characteristics, findings may be generalizable to some degree. The great strength of case studies, therefore, lies not so much in telling us what tends to happen, or what will happen, but what can happen. Before asking whether a specific intervention is, typically, effective it is vital to ask whether it is possible for it be effective – and that is what case studies are good for. Thus, they do not address questions like “does online therapy work?”, but rather “can online therapy work?”

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In the last ten or more years, case study methods have also evolved considerably, notably with the introduction of systematic case study methods (Stephen and Elliott, 2011, for example). When taken as a whole, a series of case studies with characteristics in common – such as their use of a specific technology – can then also form an evidence base of a quite different type than, say, a randomised controlled trial (RCT). The latter will tell us little about any individual other than, typically, change in quantitative measures of distress often recorded on some kind of psychometric indicator. The former, in contrast, will offer a far more rich and detailed impression of what happened, allowing much better assessment of what contributed to change, of problematic features of the intervention and so on. Initiatives like Fishman’s Pragmatic Case Studies in Psychotherapy (Fishman, 1999; 2000; and see http://pcsp.libraries.rutgers.edu/index. php/pcsp), Elliott’s Hermeneutic Single Case Efficacy Design (Elliott, 2001; 2002; Elliott et al, 2009) and others have been seen as offering an antidote to many of the problems associated


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S t ep h e n G o ss

Research herapy with the large scale, broad brush view offered by studies involving large numbers of individuals – a route to developing practice based evidence, and evidence based therapy relationships (e.g. Elliott et al, 2010), rather than just the narrower version evidence based practice and empirically supported treatments (Rowland and Goss, 2000). Examples abound and only a few can be mentioned in the space available here. Rothbaum et al (1999) report a detailed case study of using virtual reality (VR) to treat PTSD among military service veterans and even earlier reported cases involving similar work for those with acrophobia (1995) and for fear of flying (1996). Carlin et al (1996) report a case that utilised the interesting extension of VR that includes tactile sensation in addition to visual immersion in the environment for arachnophobia. In 1999, Brice offered a demonstration of therapeutic work via e-mail, at a time when many in the profession still questioned whether it could ever be viable. Roy and Gillett (2008) later demonstrated the

potential of e-mail in building therapeutic alliance with hard-to-reach populations through the example of high risk young people otherwise reluctant to access support. Botella et al (2002) also demonstrated the use of more recent software for fear of public speaking. Notably, their case reports acted as precursors to a larger body of work that included more wide ranging research and development – an example of showing what can be possible before systematically searching for what usually happens. Daley et al (2005) have described the use of the Internet itself as a developmental tool in use with an adolescent boy with psychosis while Palmer (2004) looked at the integration of several modes of support at once as an enhancement of REBT (Rational Emotive Behaviour Therapy). Kersting et al (2011) show another use of case studies in giving concrete, specific exemplification of a concept they were presenting regarding Internet therapy following pregnancy loss. Hsuing (2002) also offers a range of additional case material, as do numerous other sources (e.g. Anthony, Nagel and Goss, 2010), although it is worth bearing in mind the difference between formal case studies, as such, and less structured and detailed reports of case material. Of the special issues of interest to online therapists, is the relative ease with which whole records of the therapy process can be made available for analysis. Where practitioners use written communication methods (email, chat continued next page

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etc.) the entire transcript is already available, representing a significant time saving.

and the proponents of evidence based practice to be the entire reserve of controlled trials.

Furthermore, transcripts of multiple cases can also be submitted to enhanced analysis techniques, some of which can be semiautomated through keyword searching or software tools designed specifically for qualitative research. While no software will ever be able to replace the perceptual acuity of a human researcher, it is entirely possible to track emotional expression and specific topics, through developments like ‘sentiment analysis’ (Allen, 2002; Das and Chen, 2001; Agarwal and Bhattacharyya, 2005; Airoldi et al, 2006) more usually applied to the vast scale of behaviour exhibited in whole Internet communities, for example, and to identify trends even in extremely large agglomerations of case material – the potential being vividly demonstrated by the non-therapy related mood-of-the-Internet community indicator that is We Feel Fine (Kamvar and Harris, 2011). Thus, it is possible that the records of textbased online therapy – equivalent to readymade transcripts of the whole of a therapeutic process - may be capable of being submitted to a kind of analysis that combines some features of individual case study (n=1) methods such as the idiographic expression of how a person feels with the statistical and predictive power traditionally thought by outcome researchers

At the other end of the spectrum, many practitioners already are undertaking case study research, informally, without realising it. Regular supervision and case discussion work is the start – by adding routine change indicators (whether psychometric or otherwise), maintaining detailed notes and submitting them to a recognised process of analysis and formalisation (see McLeod 2010) it is a more straightforward matter than many practitioners realise to convert your work into part of the literature and in so doing to contribute to the growing, and increasingly influential, body of practice based evidence. n References for this column are at the Online Therapy Institute blog

ABOUT THE AUTHOR 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 the TILT Editor at editor@onlinetherapymagazine.com Subject line: Research Review.

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FOLLOW

Research Call

ONLINE COACH INSTITUTE on Facebook & Twitter

Dr. David Haniff is working with MK Mind, a local mental health charity to create a game to help people with depression, and his work is featured in our article on page 9, (“A Serious Game to Help People with Depression�). He would like to invite readers to play the game and fill in a survey afterwards to get as much feedback as he can. Link to Game & Survey http://www.pervasive-technology-lab.org/Life_Choices_Game/ deploy-to-web/main.html

Dean McDonnell, a final year MSc in CyberPsychology student studying in IADT Dun Laoghaire, Ireland, is conducting research into the attitudes of therapists towards the use of computerised therapy. The goal is to is to research into the use of Artificial Intelligence for the ultimate aim of designing a programme specifically for therapists to use to conduct additional methods of therapy. If you would like to know more information regarding the research or wish to participate, please contact him. CONTACT 085-1617013 phone deanmcdonned@gmail.com SURVEY LINK https://www.surveymonkey.com/s/JNCD3Y7 LINKEDIN LINK http://ie.linkedin.com/pub/dean-mcdonnell/20/31b/998

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What Would You Do IN THE LAST ISSUE WE ASKED:

Your face-2-face client has been talking about the virtual game, World of W for several weeks. While you try to listen intently, you really don't unde what WoW is or how it might be relevant to your client's therapeutic go What would do you?

ponds:

Audrey Jung, LPC, DAPA res

rt of developing and s of a client is an important pa nce ere ref al tur cul p po the I believe that understanding ance. maintaining a therapeutic alli nt to share with me Warcraft, I might invite the clie of rld Wo of e dg wle kno any ORPGs during If I did not already have do my part to read up on MM and , ces en eri exp ing gam worth t his a little bit more deeply abou e as a cultural subtext that is gam s thi to s nce ere ref t ten at his persis my free time. Basically, I'd tre of life reference. us belief reference or a stage igio rel a to ly ilar sim , ing and underst s continued anding regarding the client' rst de un r are cle a op vel de gin to tween his virtual and As we work together, and I be ess for signs of imbalance be ass to gin be uld wo I r, tte ma munity and virtual discussion of this topic d of gaming addiction or com fiel the in s list cia spe to nt l issue of clie unplugged life, referring the gaming itself is not the clinica the t tha ars pe ap it , ver we ho sary. If, nces in our cognitive work resources if that became neces ng these pop cultural refere usi ue tin con to nt clie the e concern, I would encourag the clien together. re relevant and engaging to mo ls de mo l ica clin er old ture to make the nitive-behavioral Typically, I try to use pop cul sions as they practice their cog ses een tw be in n ow ir the on e's lack of so that they may recall them rtant to be genuine about on po im is it t tha e liev be I h tion, thoug re. Clients, especially homework. One word of cau inviting the client to share mo by ne do be can s thi and a, uncomfortable knowledge in a specific are bond with them through an to pt em att n's icia clin a gh ou young adults, can see right thr nce. ere ref ard kw usage of slang or aw

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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.

NEXT Month's dilemma You are a coach or therapist and you have been engaged with a client using individual chat and support group discussion forum. This client was referred to you through a wellness center in your local community and your sessions have not utilized an audio or video component. Your client has requested an inperson session at your office. What concerns might you have about making this transition?

What would you do?! Weigh in at the OTI/OCI Social Network’s Discussion Forum!

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Zen

TILT – Therapeutic Innovations in Light of Technology

and the Art of Inbox Management

by Christine Korol 22

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Email is my arch nemesis. I have tried almost every recommended approach to minimizing, filtering, limiting, filing, and delegating in a somewhat successful attempt to limit its encroachment on my life. I owe a great debt to Charlie Gilkey, Sid Savara, David Allen, Tim Ferriss and many others who have thought long and hard about how to handle email overload. Without them, I wouldn’t have time to write this article. Unfortunately, I still find myself locked in a struggle between the work that I want to do (e.g., draw cartoons,

write blog posts) and the growing lists of new messages demanding (but not receiving) immediate attention. I feel the same frustration towards email that I do towards housework, errands and any other task that adds to the busyness of my day. A simple approach to dealing with frustration is to ruthlessly eliminate the obstacle that stands between you and your happiness. Dr. Sherry Turkle coined the term email bankruptcy to describe the decision to delete an


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overwhelming number of messages. My first experience with email bankruptcy was when the Psychology Department secretary where I used to work announced that she had deliberately deleted everything in her inbox. She informed us that if there was anything important that we should resend the message. Everyone in the department was aghast but we understood. More than a few were tempted to do the same. Every now and then I still fantasize about living a life free

of email. Completely cut off from the world, with nothing to do but write and draw all day. I also fantasize about having a live in chef, housekeeper and a personal trainer. Until that glorious day, the only feasible option I see is practicing non-resistance as I work my way through the bottomless pit that is my inbox. I eliminate what I can, focus on what is important to me and treat the distractions that frustrate me as an opportunity to develop patience and equanimity.

If I ever come up with something better than that, I promise that you will be the first to know!

ABOUT THE AUTHOR/ ILLUSTRATOR: Christine Korol, Ph.D. is a cartoonist, psychologist in private practice in Calgary, Canada and the host/producer of a podcast on wiredtoworry.com that provides free online anxiety and stress reduction education videos.

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TILT – Therapeutic Innovations in Light of Technology

Composing Onesel

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by Cedric Speyer and Eusebia da Silva

lf in E-Counselling A Case Study

"I had no idea it was possible to form a bond and trust with someone based solely on the written word" —E-counseling client

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Introduction E-counseling fosters getting it down in writing, seeing it in print, and composing oneself – all therapeutically beneficial, even before the first ‘session’ begins. What might be lost from the immediate give-and-take of ‘live’ conversation becomes a gain. The process has all the advantages of introspection while still being part of a clinical dialogue - one that takes place behind the scenes of appearance and personality in a shared space on the internet. The online counseling transcript featured below is an abridged demo case based on the work of Dr. John Yaphe - client details have been modified so the correspondence is not identifiable. The usual comprehensive online intake has not been included and only the initial client-counselor exchanges are presented. Minor mistakes in grammar and spelling have been left to preserve the veracity of the transcript. Case commentary/session notes are featured in italics. The client is a 42 year old woman and mother of two children who was recently widowed. She works as a mid-level manager in a large corporation.

Cynthia’s description of current situation My husband died just over a year ago, from cancer, and I thought I was doing ok but I'm feeling alone and disjointed with life. I can't seem to focus at work and I don't really want to do much of anything. I’m just trying to keep my head above water. Having a management position within the organization adds a stress level of its own. How do I go about putting some focus back into my life? Tough question I know. I need to talk to someone and feel like there’s no one who understands what I’m going through. Life pushes you on to keep moving but I am still stuck back there. I am moved by what this client is not saying, as well as what she reports, in describing the aftermath of her grief. She wants to move forward with her life but feels like she’s treading water. I sense the need for some ease and flow in her life. She seems to be a high achiever.

Hello Cynthia, Welcome to E-counseling, where we can exchange several back-and-forth letters, in this confidential shared space. My name is John and I will be your e-counsellor. I am here to help understand what you’re going through, so I’m glad you chose this way of taking care of yourself. I hear that you’re at a crossroads and want to find a way forward. Together, we will look for the path ahead and the life you can make whole again. My heart goes out to you. As a young woman, you have suffered one of the most difficult losses, that of a life partner. Of course you would be feeling the way you do, even a year later. In fact the resurfacing of what happened “back there” is called the ‘anniversary reaction’ when it’s around the same time of year. Feeling alone and disjointed 26

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is a natural reaction to loss. So is a lack of focus and a lack of enthusiasm for work. It is called grief and it is one of the most powerful human emotions, like love. There is no timetable for its after-effects. Although there are stages that everyone seems to go through, there is great wisdom in letting nature take its course. While reading about how you’re trying to keep your head above water I was reminded of how the course of grief is often compared to a series of waves… fight them and you can drown… surrender and they carry you to shore… I am validating the client’s present state, without judging it. She feels she should be further ahead and expects much of herself.

Grief is usually very private. If it feels right, I would like to hear about your husband, what you loved about him and your experience of ‘good-bye’; how you felt during his illness, and what family life means to you now. Most religions have rituals for public expressions of mourning and these sometimes help us through. Has this been significant for you? We all heal at a different pace. What would you be doing differently in your present life if it didn’t feel like you were still “stuck back there”? How would we know when Cynthia has got her focus back? What would that do for you and allow you to do? I would like to know what would help restore purpose in your life and how you have already tried to achieve that. I imagine there are a lot of other people in your life who you love and who love you. How are family and friends helping you now when you need their support? I am looking for the client’s strengths and resources and exploring what works for her.

Cynthia, I like your tough question about regaining emotional equilibrium. Death is disorienting and

upsetting and can make a mess of life for those left behind, no matter how much we would like to master stages and strategies to deal with it. Like love, it’s better approached as a pilgrimage full of unknowns and uncertainties. I hear your need to get on with your life, yet the ongoing pain of the loss touches me also. How can I offer support for both these needs? Kindly, John (Dr. John Yaphe)

Hi Doc Thanks for the email, reading it brings tears to my eyes. This week I'm at the University of A. on a techie course and it is the first time in over a year that I have been away by myself. I had hoped so much that this time alone would help but I'm not so sure. You asked about religion, I have kind of given up on that, thinking that God really hasn't been paying attention or something lately. I'm thinkin' that will have to be a whole different path to repair in my life at some later date. My husband was an amazing man who loved me and the kids more than anything in the world. He wasn't perfect by any stretch but he did make our lives full. A fact we all feel so much, the hole he left, especially for my daughter. We had some very special times before he died because he wanted to die at home so we looked after him at home till the night he died. I miss him so much. Writing this is so hard....I don't get to cry like this at home, everyone worries so much if I do and I can't do that to the kids, they have been through enough they don't need to worry about me. I took a little time from work but I have so many things going on that being away is so hard. I'm not good at asking for support so many people have no idea how I'm feeling. What have I done, I don't know but these last few days have given me the idea that I have been hiding away from life. I had hoped that being in school with T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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new people and new ideas would spark that new chapter to my life and maybe it will… I'm not holding my breath right now. I don't know what to do... is there a magic cure....... a pill or just life and time?? I hate feeling so alone and I want so much for someone to just wrap their arms around me and hold me. That need in itself is causing self destructive behavior. This is a red flag for risk to the client that I will assess further in my reply.

You asked how you could support me. A hand to hold, a hug.......if you can figure out a way to send those... a lot of people like me would want them.......... :) Cynthia

Dear Cynthia, Thank you for your warm, authentic reply. You said that you are not good at asking for support and telling people how you feel. Your letter tells me just the opposite. You asked very openly for help and you expressed your feelings so directly that it gave me a good sense of your goals. Now let’s see if we can walk together a little further along this path. We use the CARE approach to guide e-counseling. The CARE model is a general framework for short-term case management. The first letter in the acronym stands for Connect & Contain. ('Your challenge is human and manageable'). I offered empathy for Cynthia’s emotional state in the initial exchange and contained it within the normal context of grief and mourning. Now we can begin to offer the client a bigger story to live in than the one she was telling herself at intake.

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You nursed your husband through his illness and you were there for him until the end. These are special moments in our lives and they stay with us forever. I am struck by your frankness in talking about your husband. Nobody is “perfect by any stretch” as you write. What is striking here is your ability to be honest. It is OK to remember the blemishes too. What is important is that you conclude with “he did make our lives full.” The fullness you experienced can be part of your healing. When someone dies, the sharing of this life’s journey comes to an end. Yet without their physical presence, personality, and all the life-giving interaction with them, something else emerges… their essence. Does this resonate with you in any way, Cynthia? Of course writing about what you’re feeling is not so easy. Yet you’re doing it really well. You write that you don’t get to cry at home because you don’t want to


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things happen in this world. I like the opening you leave yourself in the sentence “that will have to be a whole different path to repair in my life at some later date.” There is an optimism and fundamental truth in that statement that needs no further comment. It will grow naturally in you as everything does in time. It’s good to hear that you are taking the course at the university. That is a big step you have taken and answers my questions about what it would look like if you moved forward. This course sounds like it is teaching you more than the technical stuff in the program. You write that you thought you were hiding from life. I don’t know about that. Sometimes we have to go into a cocoon to come out stronger later. I like that line about the new chapter in your life. Hold onto that need inside even when signs of it are not apparent in your life yet, visualize exactly what it would be like, and sooner or later you will find yourself living it.

worry others and what will it do to the kids and…. yet crying is the most natural aspect of grief and we need to do it. We can run into problems if we don’t cry. Your kids need to cry too and need you there to comfort them when they do. It’s OK to cry at home and for your kids to see you cry. It’s OK to talk about it too and say what you feel about Dad and what you miss and what’s not fair and what you’d like to do to remember him. The ‘A’ in CARE stands for Assess & Affirm. ('You've got what it takes to get through this'). We find that Cynthia has her own good instincts that will guide her progress.

About God and religion and the Big Questions: I’m not an expert on that. Some of my religious friends say that “God’s face is hidden from us” when really terrible

The ‘R’ in CARE stands for Reorient & Reaffirm ('You are not defined by your life situation'). Cynthia can look at her life situation in many different ways, some of which I have suggested.

I am concerned about that throwaway line at the end of your letter on “self –destructive behavior” coming from the simple human need to be touched, held and comforted. What did you mean? If the desire is for touch, your husband’s particular touch will not be replaceable, but I’m wondering if you can seek loving touch now, from friends and companions who can give and receive hugs. On the other hand, a mystic once said that “everything that can be had in a hug is right here.” That refers to the inner warmth and consolation found in your own heart. In our remaining exchanges, I would like to hear about your own ways of accessing that. Feel free to write what’s on your mind and in your heart. I’m here and I’m listening. John

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In addition to the assessment of risk, I am also invoking the ‘E’ of the CARE model, Encourage & Empower. ('Keep going, one step at a time'). We believe Cynthia can get past her impasse. At this point, I introduce closure to prepare the client in advance, knowing it might trigger Cynthia.

Hi John, I have to say that your last paragraph was a moment of awaking for me the day I read it. You’re still here but you won’t be for long. :-(

Cynthia understands that we will reenact another loss here and move on.

Being back home and in my nature environment I realize it will be much harder to accomplish what I had hoped by starting fresh with a focus and moving through life. Home seems to bring the reality of everything back and the day to day issues that come are there in hordes. One thing I have realized is that I like me and my life and the rest will heal as time goes on and everyday will be one more and it could be up or down. I need to ensure that the kids have this message and that we focus on our lives and making them rich and full. The "self destructive behavior" is exactly that, drinking and one night stands, and I need to stop I realize that, I'm just not sure I can yet. It is a form of running a pattern I know well. You run so you don't feel the pain and stopping can be hard but it will only happen when you are ready to, which can be dangerous. I think that is all I have to say today, I feel tired and sad. I’m back at work and I’m hoping it will help 30

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me take my mind off myself and concentrate on what needs to be done. How do you go on with life, moving through day to day is easy but make plans for the future, how? Maybe that is too much at once, maybe it should be one day at a time, then one week at a time and the rest will come together naturally. In theory that is all good, but I'm so impatient I can't wait for that to happen so I go out and make something happen then I end up in something I shouldn't be in. How or where does the next phase come from? Reality is at the door, time to go to work............ Thanks, Cynthia

Hi Cynthia, Thank you for responding with your usual straightforward honesty that lends a lot of good perspective to this dialogue. I respect and admire you for the way you are dealing with a reality that can feel unreal and unproductive at times. Yet in the middle of your letter you say “I like me and my life.” Good to hear, Cynthia! That kind of bottom-line self-acceptance is a foundation for change. You also have the wisdom and strength of character to write that beautiful line in your letter about the ups and downs of everyday life and keeping the “focus on our lives and making them rich and full.” That sounds like you are dealing with the key question of “focus” from your first letter. There is great freedom and fulfillment in giving others what you most need. In your letter you wonder how you can break old patterns and move to the next phase of life. Did you take a plane to get to your course? Have you ever flown in a cloud or over the ocean? You are sitting in a plane with no indication that you are moving at all and all the time you are hurtling along at 800 kph. Then you start to land and your stomach is in your throat


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and suddenly you’re in a totally different place, where you wanted to go. It can happen like that. I hear some healthy self-confrontation in your concern about the “self-destructive” behaviors. When I read those lines, I also hear the need for real love and the strategy for finding it that you already know leaves you in a lonelier place. I see that you have a good understanding of the pattern as a shield against the pain and frustration you feel at times. When I realize that you have this insight, I know one day you will get back to celebration of partnership and intimacy as a true expression of yourself and not as an escape. It can happen when you’re ready. I reinforce Cynthia’s responsibility to herself while issuing a vote of confidence in her integrity.

“Reality is at the door, time to go to work…” you say at the end of your letter. That includes the good work you are doing here. In your next letter to me I would like to hear about the how and where of the next phase as you put it. I’m wondering how your “one day at a time” resolution is energizing you. Is the voice of impatience a little less demanding? This journey is like walking through a dark forest with only a flashlight in your hand to guide you. All you need to move forward is that little beam of light showing where the next steps need to taken. John

Hey John, It has been a little time for me to come to the computer. I need some quiet time to myself to write and I have found a moment of solitude. You asked some specific things in your last note. The next phase, well I'm into it. I still can't believe the impact that week of being away has had on my life and my perspective of life. I have come to a very comfortable

and quiet place within myself that had not been there prior to that week. It was like a weight was lifted, by allowing time for myself. I was able to see life in a different way, without the fears, guilt and pain. I do know what you meant in the first email by the person being gone but you can still feel the best part of the person. Sometimes it helps to remember my husband that way and sometimes it is a total resurgence of the anger and total confusion as to why… why… then something steps into my heart and my head that gives thanks for having been with him for the time I did. I need to be grateful for this and move on. Not an easy task. I get what you mean by just focusing on the next steps because that’s all we can see ahead. Being back at work is a challenge with the demands being great and while I think for the first time in a long while I am better prepared to cope with it, there are many ups and downs. I just need to remember T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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that working all the time is not the answer to living - a tough one since this is where I have been hiding for some time. Your comment about the clouds was so good, I read that over and over and it became so clear to me. That was exactly right, I was all fuzzy and the clarity has arrived and the clarity isn't from anyone it is from within that it has come, which is really the only place it can.

h

Thank you, Cynthia

"Words can sometimes, in a moment of grace, attain the quality of deeds." —Elie Wiesel

The text-based bonding that enlivens E-counseling is characterized by tele-presence, or the feeling of persons being next to each other, even at a physical distance. As we can see in this case, both insight and catharsis are possible in a contained environment as a window is opened to mindful reflections on both sides of the computer. In subsequent exchanges, Cynthia strengthens the self-awareness we see emerging earlier. She processes the mixed feelings raised by the “complication” of a new romance. Although she would struggle with the “finality” of closure, Cynthia concludes that the online correspondence helped restore the flow of life, once she began honouring and making room for her inner life. The text itself, the transcript of the dialogue, serves as a ‘transitional object’ facilitating self-compassion, as she gradually internalizes the encouraging words of the counsellor into a self-validating voice of her own. n

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ABOUT THE AUTHORS Cedric Speyer, M.A., M.Ed. pioneered Shepell•fgi's groundbreaking E-Counseling service in 2000. He conducted the first few thousand online EAP cases in Canada, and is currently Clinical Supervisor for a staff of 35 E-counselors. Cedric co-edited Online Counseling: A Handbook for Mental Health Professionals - 2nd edition. Cedric cofounded InnerView Guidance International with Eusebia da Silva, M.A., M.T.S., Community Chaplain, Pastoral Counselor and Spiritual Director. Thanks to DeeAnna Merz Nagel, LPC, DCC, co-founder of Online Therapy Institute, and John Yaphe, MD, CM, who were clinical consultants for this case study.


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REEL CULTURE

Jean-Anne Sutherland

Cyberbullying

It’s Quick and It’s Easy I recently watched the ABC Family Movie Cyberbullying with my 13 year old daughter. Of course, triple and even quadruple media-tasking is normal for her cohort so it was neither unusual nor particularly distracting for her to keep one eye on Facebook throughout the movie. Parenthetically, she typically stows her laptop but watching a movie about a teenage girl’s experiences with a social networking site, while my teenage girl sat next to me, immersed in her social networking site, was too delightful an irony. Cyberbullying tells the story of Taylor, a teenage girl who is bullied online through “cliquesters,” the social networking site that, ahem, I am sure, was meant to bear no resemblance to Facebook. A series of events leads to Taylor’s cyber-lashing from peers in her school (a group of affluent “mean girls” in particular). As her mother pleads with her to take down her page, Taylor, much like an addict who just can’t stop, just keeps looking and posting. The ridicule and humiliation mount until Taylor tries to kill herself after posting an “I can’t take it anymore” goodbye to those peers. The mom, Kris, then reaches out to Mean Girl’s father, who merely lectures her on the specifics of “free 34

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speech.” She goes to the school principal who explains to Kris how tightly the school’s hands are tied in terms of what students do and say off of school property. Of course, what they do and say online is only murkier. She is then dismissed by a state legislator. It is not until Taylor and Kris take her story to a journalist, and their story is published, that they are heard by bureaucrats and lawmakers. A recent article noted that Facebook has surpassed email and even texting as the most dominant form of communication among young people. Apparently email is “so five minutes ago” to teens. When email entered our lives, many lamented the dying art of letter writing. Certainly, gone was the recognition of handwriting (how many of you can still picture your grandmother or father’s handwriting quirks?). Gone too was the time it took to physically write to someone, perhaps re-read it and then place the letter in the mail. We learned to write more quickly and send with frequency. With facebook as the primary mode of communication, we have another set of issues that make email look almost quaint. As you know, often teens gather in a “private” chat space and the brief, grammatically baffling one-liners appear at vampire speed (FYI, apparently vampires are really fast)! Of course, the speed is enhanced by the use of shorthand (e.g., gtg for “got to go,” L8R for “later”). Geez, who has time to write an entire word? And, who has time to


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ponder their message for tact? Research has shown that too often there is concerning lack of tact. Depending on the particular sample, anywhere between 10 and 40% of teens report having experienced cyberbullying. The greatest concern regarding the predominant use of Facebook among adolescents is the very public nature of the communication. Back in the good old days, bullies were typically physically aggressive; prone to shoving and hitting. Now, a bully needs only a cyber audience and power derived not from muscles but from popularity. As one of the teens notes in Cyberbullying, those who are bullied used to be able to go home, and leave it. Now, the bullying follows them home. It can be ever-present and relentless.

The movie Cyberbullying, as it was meant to do, provided a nice jumping off point for my daughter and me to discuss the dynamics of Facebook chatter. Like the mother in the movie, I was reluctant to let my daughter wade into the sea of Facebook (I clearly relented, but with the stipulation that I could pop into her account anytime and take a look around). Watching the movie allowed us a glimpse into the trauma and prevalence of cyberbullying as well as ways in which one might react to seeing this sort of stuff online. Not a bad way to spend an evening with your kid. With increased awareness of the phenomenon, we can only hope that fewer and fewer kids experience the kind of suffering that, outside of the movies, has actually led some teens to take their own lives. It isn’t cute. It isn’t “kids being kids.” It’s horrific in a way we are only just beginning to understand. Perhaps as we continue to discuss teens and cyberbullying, we can all learn something about discretion, tact and, the ramifications of meanness. FURTHER READING Fact sheet: http://www.cyberbullying.us/ Cyberbullying_Identification_Prevention_ Response_Fact_Sheet.pdf Cyberbullying laws: http://cyberbullyinglaws. wordpress.com/

BUY NOW

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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Counselors give telephone advice in a variety of settings. The counselor who responds to a client’s question about an urgent problem or who takes a patient’s call about advice on how to handle achallenging situation is in a position to provide valuable information and make important assessments. But in their eagerness to help clients, counselors must be careful not to expose themselves to legal risks. Here are some tips to protect yourself while providing clients with quality information. Consistency counts Consistency helps ensure that questions are answered completely and effectively. Algorithms, protocols, and responses to frequently asked questions are useful tools that also reduce legal risk. Tools should be predicated on current standards and evidence, so be sure to review

LEGAL BRIEFS

CAUTION Telephone Advice

them on a regular basis and update as needed. Counselors who will be responding to questions should receive special training in how to conduct an assessment over the phone. If it isn’t written… In the hectic rush of the day, it’s easy to neglect documenting telephone calls. Treat each clientrelated telephone call the same way you would a face-to-face visit: Document the conversation, the advice given, and any follow-up instructions given to the client. Conducting a regular review of documentation will help maintain quality and identify areas of improvement. Counselor-client relationship Remember that giving advice over the phone establishes a counselor-client relationship. Keep your telephone skills sharp so the relationship yields positive results.

Reprinted with permission from Healthcare Providers Service Organization (HPSO); 159 E. County Line Road, Hatboro,PA 19040 1-800-9829491 HPSO Risk Advisor 2011-2012.

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TECHNOLOGY ENHANCED D January 2012 A Look Ahead Welcome to the first in this year’s series of Technology Enhanced Coaching columns. The emergence of another new year and all of the technological advances it is sure to bring provides us with a fresh opportunity to pause and reflect on where we’ve been and where we’re headed. As we turn our attention to this year’s review of apps used to enhance coaching and wellness I’d like to take a moment in January’s column for broader reflection on our use of technology and its impact, for better and for worse, on and in the lives we live. While there are countless examples of how technology aids communication and enhances our ability to learn and interact with others, I think we can also appreciate the dizzying pace of technology and the implications it holds not only for the way we work, but its impact on our humanness, our being in relationship with others in general. Consider for a moment how the advent of email and ubiquitous access to the internet via wireless laptops, smart pads, smart phones and apps for everything leaves us feeling constantly engaged in technology-aided information processing. Providers of technology hardware such as smart phones are so cognizant of the potentially negative impact on human interaction that they’re

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now even addressing it, in a humorous way, in advertising that depicts the relational price paid when a suitor “gets caught” watching the football game on the smart phone on his lap and out of the view of his date. While helpful in so many ways, technology also extracts a costly toll on our ability to participate in the naturally healing and restorative rhythms that occur in a state of separation from work (rest). This technology-impact on our human and biological capacity to live and work is addressed in the writings of futurist Ray Kurzweil. Kurzweil introduced "The Law of Accelerating Returns" in a book written nearly 13 years ago entitled, The Age of Spiritual Machines. Kurzweil’s Law of Accelerating Returns states that the rate of change in technology, and other evolutionary systems increases exponentially. His view is considered to be, in part, an extension of Moore's Law which describes an exponential growth pattern in the complexity of integrated semiconductor circuits. Kurzweil points out that as we discover increasingly effective ways to do things, our ability to learn is also accelerated. According to Kurzweil


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D COACHING Lyle Labardee this dynamic ultimately leads to a point where m a c h i n e intelligence surpasses h u m a n intelligence leading to "Singularity" w h e r e technological change is so rapid and profound it represents a "rupture in the fabric of human history” marked by the merging of biological and non-biological science (http:// en.wikipedia.org/wiki/Accelerating_change). Are we there yet? We’re already seeing examples of the merging of biological and non-biological science, e.g. microchips implanted in clothing and, in applied research settings, even under the skin. iPhone’s new application Siri and soon-tobe-announced successor, “Assistant” may also be viewed as a giant step closer to the merging of biological and non-biological science. In his Mashable Tech Op-Ed article, Ben Parr writes, “The key though is that Assistant will learn. It will figure out what results you don’t like, what restaurants you frequent, and what people you want to talk to the most. It will adapt to your needs …..” (http:// mashable.com/2011/10/03/iphone-5-assistant/).

While the value this technology holds for us and the way in which we experience life and in some ways overcome challenges and even disabilities speaks for itself, the potential for this technology to start over-riding and negatively impacting other vital aspects of our lives is also readily apparent. Perhaps one of the most graphic and concrete examples may be the high rate of traffic accidents and fatalities now associated with phoning and texting while driving. So as much as we have reason to be interested in and excited about how advances in technology enhances coaching and other meaningful human interactions, we may also want to pause and remind ourselves of the importance of never losing site of our higher calling: to be fully present in all of our God-given humanness to those we serve, to facilitate their journey to achieve their personal goals and all that they endeavor to be. And along the way, let’s bear in mind that sometimes the most important experience that we can help our clients discover for themselves is re-discovery of the creative and restorative power of non-technology-enabled rest, “pure rest”. n

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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by Kasia Zukowska


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One man’s “magic” is another man’s engineering. —Robert A. Heinlein ge.

An incoming messa

yEK9+ma2VUA/6 Ky oZ ax A es /r Rp O N lUPziW --uvQlc+xIFlewrn4d TA DA TTAR -S PT TA-RY --EC ==--ECRYPT-END-DA VwnvekBTafApA9AAAAAAAAAAAAAAAAAAAAAA n morphing into to ut b a of h us p a t with ring of characters. Ye st le ib ns he re p m co An in something legible. ed analysis report.”

ch “Please see the atta

“Thank you I will send my comments by end of day tomorrow.” I respond. A single click and in an instant my message mutates into an inscrutable string of characters of its own. Encryption. Magic at my fingertips. An indescribably powerful technology, packaged in an intricate collection of code. I couldn’t begin to fathom the complexity of today’s encryption process that converts a simple message into its ciphertext interpretation. I couldn’t begin to explain the mathematics which make sense of it all. But then again I don’t understand how tiny cells floating in the air carry my voice across continents either but that doesn’t prevent me from using a cell phone. During my time working in the industry I have seen many eyes glaze over at the mention of encryption or cryptography, as though mid sentence I suddenly began speaking an alien language, words one might expect to come upon in a sci-fi thriller but ostensibly inapplicable to our every day. With increased media coverage of cyber crime, today more than ever the word encryption is thrown around like a dirty T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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tissue. Over time, yet seemingly overnight, we’re becoming reacquainted with this ancient technology. Yet I cannot help but wonder if the time lost between then and now has impacted our enthusiasm towards it...? The word cryptography has its origin from Greek: kryptos (meaning “hidden” or “secret”) and graphein (meaning “writing”), and that is in essence what it is: secret writing. Encryption is to cryptography what composition is to poetics, it is the actual process of obscuring information. In a nutshell? Cryptography is the craft, encryption is the action. Once upon a time cryptography was a very common thing indeed. Then it was an art coquetted with and enjoyed, a tool used by lovers to evade discovery, a method for governments and religious leaders to secure communications, and a means for craftsmen to protect their intellectual property. The earliest known use of cryptography dates back to 1900 BC in the form of non-standard hieroglyphs carved into monuments from the Old Kingdom of Egypt. In Mesopotamia researchers

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discovered clay tablets dating back to 1500 BC containing things like encrypted recipes for pottery glaze. Ancient Hebrew scholars and Greeks dabbled in it, and books on it where published as far back as 800 AD. From the Chinese to the Navajo, from Edgar Allan Poe to Da Vinci, cryptography was employed around the world for eons to intrigue onlookers, shroud messages, and protect information. Now, encryption is a seemingly unattainable and mysterious technology perceptibly reserved for governments and big business. Now encryption is a dualuse technology and potential threat to national security. In the US its export is regulated by the Bureau of Industry and Security, the same body which oversees the export of nuclear and biological weapons. This elevates its mystery, makes it sort of threatening, and surrounds it with a certain taboo. Generally speaking, it is intimidating. At least, we are intimidated by the complex technology that it tends to be presented as today, the terms in which it is described by technologists and engineers,

and not least the perceived effort and cost it requires to implement. But like a microwave, regardless of its hidden complexity, broken down it’s a quite ordinary thing. A microwave heats food = encryption locks information. It can be as complicated as the scrambling of satellite signals to prevent piracy, or as simple as a two school children speaking Pig Latin. Word Jumbles, Anagrams, Acrostics and Find-a-Word games are all examples of cryptography used for entertainment and mental development. Teenage slang and “leetspeak” are forms of encryption intended to obscure the true contents of conversations and messages. Tic Tac of the racetrack and hand signals in baseball games are also forms of encrypting information so that it may be deciphered only by those who possess a special knowledge, a key that determines meaning. The taboo surrounding encryption is largely the creation of government and enterprise; it’s intended to keep us at arm’s length, making it something of a privilege. Eric Schmidt, CEO of Google put it this way: “If you have something that you don't want anyone to


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and renders us powerless over the virtual distribution of the pieces that make up our individual selves and exposing us to certain risk. We’re becoming a commodity; our profiles are merchandise traded between corporations and criminals in the name of profit. Pushed into giving more under false pretenses with mantras of “social norms”, if you don’t embrace the frivolous sharing of your personal information then you are different. So more often than not we do, for a discount, for attention, for acceptance. know, maybe you shouldn't be doing it in the first place." But the truth is that for those of us who are participating members of society it’s not about having something to hide, it’s about having something to protect. Fact is, encryption is all around us: every time you connect to a WiFi network and are required to enter a password encryption is at play; every time you access a site that is prefaced with “https” encryption is utilized; and every time you try to back up a CD but can’t it’s because it is encrypted. Whether fueled by paranoia, a need for secrecy, or an inherent

desire for control, privacy has always been, and always will be, an essential element in our lives. There will always be things and information worth protecting. This fishbowl existence, where “friend” is a term more representative of our contacts on Facebook than the people who are a part of your life, where a corporation like Gmail knows more about us than our parents, where we haphazardly share our most intimate thoughts and moments with millions of strangers, this is a nuance of our modern technologically enabled lives. It belies our autogenetic need for privacy

But if a culture of transparency is truly that reasonable, why do we continue to whisper in each other’s ears? Lower our voices in bars and restaurants? Use code words on the telephone? Draw our blinds and shred documents? There is a disconnect between what we need and the behaviors we’re adopting. We need to keep secrets, we need to preserve the confidentiality of certain information, yet we instinctively Tweet our thoughts, “check in” to places on FourSquare, hold personal conversations on Facebook walls, and send financial information over unsecured email.

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“Your computer screen is not a wall that you can hide behind, but rather an open window through which two billion strangers are watching you.” —Head of Quebec’s Privacy Commission, Jean Chartier

The internet is like a beautiful firework, an unregulated expanse of connections. It literally envelops the earth, an invisible web-like formation of unseeable bundles of data flying through the air, bouncing between satellites, and flowing over cables under the sea. Anything can happen here. Like international waters the internet is ripe with “pirates”, those maliciously motivated, otherwise known as cyber criminals. In contrast to the ease of committing it, cyber crime is difficult to investigate and prosecute, more often than not leaving victims feeling helpless, frustrated, violated, and without retribution. Cyber criminals conduct their operations from the comfort of their homes, without guidelines, using everything and anything at their disposal without ever

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having to request permission, coordinate with another entity, or invest much if any money into the task. They use technological means to commit non-violent crimes spanning anything from hacking, spreading viruses, and phishing, to blackmail, financial fraud, and identity theft. These are organized crimes, yielding large profits.

email than it is to encrypt it. Why? Because we’re estranged. Because we’re lead to believe that the most effective solutions require infrastructures and IT departments and a hefty investment.

Of all the things we use the internet for, email is still one of the most predominant activities. It is the prevalent form of communication: more convenient than a face to face meeting, quicker than a letter, more accommodating than a telephone call, and more practical than a social network. It allows us to consider our thoughts and choose our words; it provides us with the convenience of responding at a time that suits us, and including files with our reply. It is also the number one form of initial contact between cyber criminal and victim. It is also much easier to intercept, access, and manipulate than letter mail. It is also the most commonly unsecured form of transmitting sensitive information on the internet today. Why? Because the perception is that it is easier to send an unsecured

Cyber criminals depend a great deal on the one vulnerability that is the flaw to most systems: the human being, one of the most difficult vulnerabilities to overcome. Not because human beings are not capable however, but because these days we can be, let’s face it, lazy.


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Convenience frequently outweighs caution. It’s a shared tendency that does not discriminate between age, gender or socio-economic status. The “it won’t happen to me” and “I’ll cross that bridge

email password recovery question, right after posting it on Facebook. It’s why we take unnecessary chances resulting in unnecessary risk. Due to the rapid habituation of internet technology, we’ve

Joseph LaBrie PhD, explains this phenomenon as ‘learned helplessness’. “Learned helplessness happens when people don’t know enough about a problem or don’t know how to resolve it. It’s like getting ripped off at a garage – if you don’t know enough about cars, you don’t argue with the mechanic. People just accept situations, even if it feels bad.” (Norton Cybercrime Report, 2011) It is probable that the majority of internet users don’t have a concept of how dangerous decisions influenced by convenience are. It’s the difference between drinking and driving and taking a cab: when we don’t take precautions we take a chance that could either have no consequence, or could shatter our lives. With taking chances there’s rarely a middle ground.

when I get there” syndromes. It’s why we leave late and speed to get somewhere on time, drink coffee in the morning rather than get adequate sleep at night, eat MacDonald’s rather than pack a lunch, or take medication rather than vitamins. It’s why we use our first pet’s name as our secret

failed to develop an awareness of virtual hazards and the importance of caution. We’ve become complacent, accepting cyber crime and the unsecured flow of data as side effects of the internet, damaging but unavoidable. Associate Professor of Psychology at Loyola Marymount University,

“Perhaps you notice how the denial is so often the preface to the justification.” —Christopher Hitchens

Recently my company conducted market research

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to learn more about what motivates someone’s decision to employ, or not employ, encryption as a solution to cyber crime. We learned that a vast majority of respondents are generally aware that their information is not private online, that others can access it, and that is enough to prompt them to take the step to protect themselves. But there was that small portion who were kindof-but-not-really interested in employing encryption technology. We wanted to know very much what their rationale was, so we asked them a simple question “Why are you not interested in encryption?” A couple of the popular answers were quite revealing: “It sounds too difficult” and “I don’t send

important emails”. It’s a sort of cop out, and a denial of importance. “I don’t want to make the effort, but I’m not important enough to be exploited anyway.” But “importance” is subjective, especially when it comes to the value applied to a piece of information, a picture, or an email. One man’s junk after all, is another’s treasure. in the case of email, any one may not in itself be damning, but it’s the collection of emails and the wealth of insight about you, the people you associate with, your habits, your work and your life, that it provides to an onlooker which can be harmful. Information that we used to only relay via phone or faxes, documents that we used to entrust only to couriers, and conversations we used to only have in person, are all now sent unguarded over the internet, naked and exposed. Accumulated all this allows criminals to compile profiles, and gain access to other worthy information using a variety of technical and non-technical methods. The fact is that over 10 million Americans who don’t believe they are important enough to be victimized have

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their identity stolen every year. The average person is not victimized because of who they are, or because someone took a special interest in them. They are victimized because they fail to take precautions. Because they where defenseless at the wrong time. When convenience outweighs our concern we become victims of convenience. Three things that make the internet especially dangerous are: 1) the threats are invisible to us, 2) we have as much value - if not more - as our possessions, and 3) we are not the sole holders of our information. Cyber crime is inherently covert. With the aid of technology criminals from around the world can reach across borders and turn on your computer while you are sleeping. A teenager in Scandinavia can hack into a mail server in the Cocos Islands and with the use of sniffers, in mere minutes rifle through billions of emails locating keywords. That guy sitting at the Starbucks focused intently on his laptop could be intercepting the last email you sent from your BlackBerry, hijacking your Amazon shopping session and making purchases using your stored credit card, or capturing


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your Facebook password because its default log in page isn’t secured. This isn’t the stuff of science fiction, it is today’s reality. What makes cyber criminals so elusive is that on the internet we can’t see perpetrators peeking at us through a window so we forget or ignore the fact that they are there. As massive as the internet is it is also terribly small: nanoseconds connect someone sitting in a basement in Russia with a computer in Minnesota. Although email gives us the impression of being point to point - that is sender to recipient - and private - because it isn’t posted on someone’s “wall” - it is a far cry from it. Truth is, digital communication is anything but direct. Like a suitcase on a transcontinental trip it passes through many hands before it is delivered to its destination. Like a postcard, its contents are visible to everyone it encounters. Like a child walking to school unsupervised it can be snatched by a passerby and exploited. Like trace fossils imprints of it are left in countless places for indefinite periods of time. Once you click send it’s out of your hands and out of your control. There’s no “undo” button on the internet. 48

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To ensure contracts remain confidential we put them in FedEx envelopes, to keep intruders out of our homes we lock our door, to prevent strangers from peering into our living rooms we draw our blinds, and to prevent credit card statements from getting into the wrong hands we shred them. And yet, on the internet, we let it all hang out.

“Cryptography is like literacy in the Dark Ages. Infinitely potent, for good and ill... yet basically an intellectual construct, an idea, which by its nature will resist efforts to restrict it to bureaucrats and others who deem only themselves worthy of such Privilege.” —Vin McLellan - "A Thinking Man's Creed for Crypto"

Through history one of the most practical and common uses for cryptography was to protect messages to ensure that only the intended recipient could access their true contents. Much about crypto has changed, but its

fundamental uses have not, and that is really all we need to focus on. Not its complexity, not the mathematics, only its purpose. In addition to vigilance, encryption gives us the technical ability to take control over the information we release over the internet, protecting ourselves, our businesses, and the people we connect with. Consider using it to protect files while they are stored to prevent unauthorized access, and emails before they are sent to defend against snooping. And most certainly enable it on your router if you use a wireless connection in your home or office to thwart malevolent connections to your network and computers located therein. It is easy to overcomplicate something as elaborate as modern day encryption. In some ways there is comfort in that: if it’s too simple than it can’t work. But simplicity should not be confused with ease of use. Most of us don’t understand all the processes involved in converting crude petroleum into gasoline, and yet using it to propel a car is easy: turn on car, press gas pedal. There is absolutely nothing difficult about the process. Likewise, encryption, although complex, does not have to be difficult to


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use. It can be as easy as: type email, click send. The pickle is that innovators in commerce sometimes like to make things more difficult than they have to be in order to create the impression of greater value. Large corporations purchase solutions costing hundreds of thousands of dollars, solutions that require a team of IT administrators to implement, configure and maintain. All of that presumably makes these solutions more effective. But in truth the more complicated something is, than weaker it can be. The more dependent it is on human effort, the more vulnerable it is to human error. The key to effectiveness is to source practical solutions that are both affordable, and don’t require a degree in computer science to operate. For too long a time now encryption technology has been largely out of reach of the average person, reserved for corporations who can afford the high price tags, and technologists who knew how to navigate it. This effectively snatched the craft from our hands, warping it into something alien and daunting. Circling back, today we have the ability to reverse this conditioning and embrace it as

a useful tool, a practical method for safeguarding ourselves and our business on the internet. We fear that which we don’t understand, but rest assured that if you understand the concept of locking a door, you understand encryption. So next time you send out an email, put it in an armored truck before sending it out into the Wild West. It will still pass through all the same hands as an unsecured one, and be susceptible to the same interception, but the envelope won’t be penetrable. It will still be stored in as many places as an unsecured email but its contents won’t be betrayed. Take control and take precaution. Be your own advocate, because no one has the same interest in protecting your information, your business, and your worth, as you do. n

ABOUT THE AUTHOR Kasia Zukowska is based in Vancouver, BC and has over 12 years of experience working with communications technology and information security in a variety of capacities, most notably as liaison to customers ranging from SMB (small to medium sized businesses) to Fortune 500 companies. A co-founder of eCrypt Technologies, and a proponent of privacy, she believes strongly that all people, regardless of their economic status, place in society, or aptitude with technology need to be empowered – through the provision of knowledge and tools - to protect this most vulnerable and fundamental human right.

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an Online Therapist

A Day in the Life of

The Journey that leads to me...as a physician practicing telepsychiatry...

When I was just a bundle of untrained synapsing brain matter, aspiring to one day to be a psychiatrist, I had no idea. I had no idea how isolating the practice of psychiatry would be although wonderful in other ways.

Sana Quijada

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Nor did I know about how practicing psychiatry would catalyze parenting into an even greater isolation. Who would have thought isolation could be described as great. But it was, like a black hole where a star used to live. I am taking the risk that you might think I am comparing myself to a celestial star. Ahem. Even so, you understand that something I considered of high value and beauty was diminished, affecting my quality of life. The natural progression of life is to effectually hone us, prune us, increase areas of productivity and diminish other distractors. For some, that works and for others, who have needs outside of what life gave them, it doesn’t. Using the biopsychosocial model, we have better perception of how this threads into our lives personally and also in practicing psychotherapies more effectively with others. The biopsychosocial model spreads over the expanse of what makes us who we are, flattens obstructions between seeing in and improves presence. What I was learning in practicing psychiatry, parenthood and the honing progression of life was that just because this is where I was, just because the current and forces on me had brought me to this wonderful and terrible combined self and just because I was acted upon did not mean that I had to continue with what I didn’t want. No. Everyone is victimized, yes? No one is treated fairly, yes? Yes, no one escapes suffering. But choosing to be or not to be a victim is everyone’s freedom. Goodness! I knew intuitively that psychiatry, parenthood and years of life were what I wanted, yet I found I was pointing outside of myself, at external loci of control to explain my condition. 52

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Freedom to choose sat near me wrapped in shiny paper and bows, unopened. I was free, by gift, but hadn’t claimed my freedom. Have you done that to yourself, like I have? Here’s the good news. Everything does start and end with “Me,” even though we find you and you, this and that, then and now in the loop of this circle; even though you are integrated into the constitution of this circle; even though without you, “Me” suffers. Even though the space between beginning with Me and ending with Me can be filled up with more than the ocean can hold, it will never sever Me from Me. Elemental to being our own friend, this is the best news I can offer for those of us who want to use our free freedom to deliberately choose not to be a victim. The steps taken daily as I practice telepsychiatry... Step 1: Insight/See in to - Everything starts and ends with Me. Years ago, I had written poetry, prose and more writing. My words used to mix into my senses well and I remembered the way they comforted me and built me up. So when I perceived I was playing the victim and no longer wanted to, I had that sensuous memory resurface, hope at its crest. I pushed my oars in and started to blog. Step 2: Acting on that insight - Start with “Me.” Blogging. Well blogging is labor intensive in many paradigms (remember biopsychosocial model.) It took away from my medical practice, from my family and diversified me. The currents that I had previously allowed to carry me, curled around my ankles and pulled. What is friendly to Me is apparently not always synonymous to “easy” or “intuitive.”


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Blogging is more than just writing, as I had done in my previous life. Blogging includes the option of disclosing what we write to any reader with a connected computer. In high school, connecting with others was promoted by all the obvious - sports, music, academics and time. Lots of time. Yet, one step or two beyond graduation and it floundered! We find that we are overextended and disconnected. There are still people everywhere but no one to know and be known by. In this condition of “water, water everywhere nor any drop to drink,” writing through blogging online surprised me. As often as splish-splash, resonance became heard. I was not alone. I compared my new experience with high school and thought, “This is even better!” The isolation I once despaired

over was used up in what improved my buoyancy. The written word is old-old but what it is doing for us now online is fresh. I cannot forget that it is technology that crafted so much of my healing process. Because of how useful it is to my empowerment and essential needs, it would not be friendly to me to forget that. Of course, because the content of what I write is therapeutic to others, we could easily say this bigger. Technology has crafted so much of our healing process - yours and mine, that it would not be friendly to us, (to “Me” in each of us,) to not use it actively, deliberately and with purpose. Step 3: Methods - Use technology. So there you have it. Once you see into the need,

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start with Me using technology as our tool. One, two, three.

We provide information and collaboration for the behavioral telehealth industry! JOIN NOW! Your free membership includes your own blog, our forums, member tweets, events and other great features! www.onlinetherapyinstitute.com info@onlinetherapyinstitute.com

Not so easy you say? Technology, the web, identity theft, patient confidentiality, HIPPA compliance - ahhh! Yes. All true, but we aren’t dummies. Use technology wisely- with encryption and check your sources. Dip a toe in and let yourself accommodate to the water. I have always adored that Saturday Night Live cast movie, Superstar, when Molly Shannon talks about jumping into a swimming pool versus going in toe first as an example of our free choice. For a long time, I was afraid to connect because of confidentiality and I suffered letting fear choose for me. Now, I choose freely. I blog and also conduct a clinic over Skype for people who for many reasons cannot be seen in clinic. My quality of life and who I perceive Me to be has all changed since. Technology has been and is something I actively choose to use, for reasons that start with Me. One, two, three.

about the author Sana Quijada is a board certified psychiatrist, a lover of books, a mom and a wife. She is in private practice and specializes in outpatient services (in person or by telepsychiatry) and ECT (Electroconvulsive Therapy) She is also the medical director of the Loma Linda University Behavioral Medical Center Partial Hospital of Murrieta. Her telepsychiatry website is Prime Telemedicine. She also hosts a blog, A Friend to Yourself.

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TILT – Therapeutic Innovations in Light of Technology

an Online

A Day in the Life of

I work in my pjs! Yes truly, I am often found in my pjs until about 10am when I suddenly realise that I’ve been working for over 2 hours and am still not showered or dressed! 56

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e Coach Jackie Walker

It’s amazing how quickly those first couple of hours disappear as I catch up with email and social media activity - Twitter and Facebook (profiles and groups), and blogs. Reading and commenting on blogs is something I try to do twice a day, first thing in the morning and last thing before shutting down for the evening. These things are my lifeline in a world where I work from home, off the beaten track, in the middle of the Scottish Borders! My best and closest friends, women I call soul sisters, were met on Twitter. As a group we meet regularly, albeit infrequently. My marketing is all done online via social media. I collaborate on group ventures and projects, create offerings, trainings and products with other people I’ve met and got to know through Twitter,

Facebook or blogging activity. It can be deemed a strange world by those who have never inhabited or investigated it. For me it’s my norm and has been for over 6 years. And, I love it! I rarely schedule any calls before 10am, and I’m always dressed before I speak to a client! That’s where my in built code of respect comes into play! Clients speak to me for a variety of reasons - my work is supporting others to get used to being themselves and learning to love themselves. For some that may mean health issues, for others relationship issues, for it could be looking for help in upgrading their soul. I coach and mentor practitioners and therapists who are ready to do their own shadow work. I do it all by phone or Skype sometimes on webcam, most often not. Much of the work I do is deep and emotional and I’ve found that I am better able to tune into clients without the distraction of video. If I’m going to do video work, I will quickly slap on some make up! I have a blogging strategy which keeps me on track. On

Mondays I record a video of me answering a reader’s question, on Wednesdays I host answers to my Being Me Interview and on Fridays I write a pertinent post addressing some form of relationship question, be it with yourself, partner, family or the wider world. This has made life much easier for me than the more random and scatter gun approach I used to have! On a Thursday I write my weekly Deeper Connection email which goes out to all my subscribers. In between I write guest posts for other blogs and am a regular contributor to a multi author blog for Women in Business - Birds on the Blog. Each day, weather permitting (yes I know I ‘should’ just dress accordingly, but I’m being honest) I take myself out for a good rambling walk in the countryside. It’s my meditation as well as my exercise. The fresh air and nature feeds my soul and provides me with such wonderful inspiration. Sometimes I take my camera with me and record wee lessons to share with my followers. If I miss my walk, I will take 30 minutes to meditate, without fail. My day usually ends around

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6.30pm with a glass of wine! However, as I also run group courses I can be found hosting evening teleseminars once a week, in which case the glass of wine waits patiently in the bottle!

ABOUT THE AUTHOR Jackie Walker is an intuitive coach therapist specialising in the field of relationships - with yourself, with others and with your world. Drawing from her training in NLP, coaching, Huna, and much more, she brings grounded wisdom to her clients which creates fast and effective change. Her website is at http:// JackieWalker.me

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Are you an online therapist or coach?

We would love to hear from you! Contribute to our "Day in the Life" columns with 500-1000 words! Submit your article to editor@onlinetherapymagazine.com


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Steven Starks

Survey

Distance Counseling The results are in! In the last issue of TILT Magazine, online practitioners were invited to participate in a survey designed to gather information about various trends in the distance counseling industry. The survey was also announced across various professional networks as well as such platforms as LinkedIn groups, Twitter and Facebook, including the OTI social network which has over 1150 members. Despite this, only 211 responses were received, which may be an indication that while many people have a heightened interest in online therapy, they are not yet practicing online.

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F

rom your answers as practicing distance service providers, much was learned about the regularity with which practitioners provide services to clients outside their own jurisdictional area, the technologies being used to communicate with clients, and the topics and skill areas most important to survey respondents. Some of the results may surprise you whereas others you may have expected. In either case, the data paints a small but significant picture of what is currently going on in the world of online therapy. For the purposes of the survey, distance counseling was defined as conducting individual, couple, or group counseling sessions in the absence of physical presence and in which a therapeutic relationship is established by an individual able to practice independently in his/her geographical/ jurisdictional area. The key components of this definition are (a) the absence of physical presence, (b) the therapeutic relationship, and (c) the ability to practice independently. Communication technologies (e.g. telephone, VoIP, email, videoconference) allow people to interact with one another in the absence of physi-

ABOUT THE AUTHOR Steven Starks is a counseling student at Walden University and an online academic advisor for University of Phoenix. He has experience in distance advising, online learning, and academic research and writing. He is the creator of the blog site DistanceAdvising.com, a resource for academic advisors serving the online student population. The author would like to thank Stephen Goss, DeeAnna Nagel and Kate Anthony for their help with this research.

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cal presence and are therefore fundamental to distance counseling. It is the absence of physical presence, however, and not the specific type of technology used to make the interaction possible, that is a defining characteristic of all distance counseling situations (hence the term “distance”). Another vital element to distance counseling is the therapeutic relationship. Interactions that occur outside the context of a therapeutic relationship, such as scheduling appointments and negotiating service fees, do not fall under the definition of a therapeutic interaction. Similarly, casual conversation between two or more laypersons does not constitute a counseling session. The practitioner role must be assumed by one who is licensed (U.S) or otherwise qualified and/ or recognized as a legitimate provider of counseling services. Voltaire once said that “the problem with language is words.” This was evident not only in defining distance counseling, but also in constructing survey questions. The international scope of the survey underscored significant differences in the laws, ethical codes, and standards of practice in various countries, making it difficult to word questions adequately. For instance, some countries require a license to practice counseling, whereas other countries may require status as a fully qualified member of a professional organization. Additionally, using the phrase distance counseling instead of terms like online therapy, technology-assisted counseling, and cybercounseling, though they are generally used synonymously, may confuse people. In light of these concerns, certain questions were constructed in such a way that made them more broadly applicable, which may have sacrificed specificity. Despite these limitations, the data revealed some clear trends based on the survey responses.


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Demographics It should be noted that respondents were permitted to skip questions that were not considered vital to the study, such as those pertaining to demographics (e.g. gender, age, education level). The majority of respondents came from the United States (107), followed by the United Kingdom (28), and Canada (20). One to three people responded from several other countries including: Australia, India, Denmark, Spain, Israel, South Africa, Germany, Netherlands, Greece, Italy, France, Jamaica, Nigeria, and Indonesia. • Out of the 175 participants who responded to indicate their gender, 109 identified as female and 66 as male. • The average (mean) age of participants was 51 years-old. The median age was 50; the youngest respondent was age 24 and the eldest was age 80. • The majority of participants reported having a master’s degree or higher. Of the 172 peo-

ple who provided this information, 57 held a doctorate degree and 99 held a master’s degree. A small number (11) reported having a bachelor’s degree and 5 of the responses were categorized as “other” because they were ambiguous or below a bachelor’s level degree (e.g. degree-level training but no degree, certificate, associate’s degree).

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technologies Today’s counselors have a variety of technology options available to them. We wanted to know which distance provision methods were the most popular. By far, voice technology was the most preferred distance provision method as nearly 66% of respondents use this option. This is not surprising considering that telephonic counseling has been around for decades and that VoIP technologies have made long-distance calling affordable (free even). Nearly 50% of respondents indicated that they use video and email options and a good number of practitioners (35.5%) reported using text-based chat and instant messaging (IM) options to deliver therapeutic services. Other technologies, such as mobile text/SMS, virtual world platforms, and discussion forums,

did not receive a substantial number of responses. Although 15 respondents selected “Other,” 12 of these responses were Skype. We learned that, of our 211 respondents, 4.7% are using e-clinics to engage clients in distance counseling services and 11.7% are using customized programmes to deliver encrypted services. In fact, the majority of practitioners can be divided into two camps: (a) those that use select programs/platforms and (b) those that do not use encrypted options at all in the delivery of counseling services. Here is a breakdown of the data. • 33% of respondents report that they do not use encrypted options to deliver counseling services • 37% of respondents said they use select programs/platforms to deliver encrypted counseling services • Of these respondents, 66.3% of them are using Skype and 31.3% are using Hushmail. • Other services being used included GoToMeeting, SAFe-mail.net, Facebook, FaceTime, iChat, and Google Chat.

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PRACTICE So just how much time, in an average week, are practitioners engaging clients in distance counseling services? Overwhelmingly, distance counseling services seem to supplement traditional face-to-face counseling services as 75.8% of you spend 10 hours or less engaging clients in some form of online therapy. Here is what the rest of respondents reported:

Do you require a face-to-face session prior to beginning distance sessions? • 75.3% said NO • 24.7% said YES

• 14.7% practice online therapy 11-20 hours per week • 6.2% practice online therapy 21-30 hours per week • 1.9% practice online therapy 31-40 hours per week • 1.4% practice online therapy more than 40 hours per week We also asked the following questions: How many of you provide distance counseling services to individuals, couples, or groups outside of your own state/province. • 30.3% said NO • 69.7% said YES How many of you provide distance counseling services to individuals, couples, or groups outside of your own country? • 44.8% said NO • 55.2% said YES T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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training and Lega We wanted to know how many of you had training beyond your degree(s) in any online or distance provision methods. The majority of you (57.7%) reported having additional training either by completing a structured training program, by assisting with the development of the field, or through a combination of these two options. Over 75% of these respondents com-

pleted at least 16 or more hours of training. Also, the majority of all respondents (64.9%) believed that training beyond one’s degree(s) in online or distance provision methods should be required to practice distance counseling. A major legal and ethical obligation of the counseling profession is to take reasonable steps to protect client information. To this end, we asked respondents (those who use encrypted options) to rate how confident they were that the technologies they use are compliant with privacy laws relevant to their jurisdictional area. Here is how you responded: • • • • •

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42.8% are very confident 29% are confident 20.3% are somewhat confident 6.5% are not so confident 1.4% are not at all confident


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al/Ethical Issues (e.g. California Association of Marriage and Family Therapists, Association of Biblical Counselors) or unique to the geographical region in which the counselor practiced (e.g. Canadian Counseling and Psychotherapy Association, British Psychological Society).

As an emerging discipline, online therapy may not be regulated in some jurisdictional areas or practitioners may not be aware of such regulations. We asked if your state or other jurisdictional area regulated the practice of online therapy and here is how you responded: • • • •

48.2% said NO 29% said I DON’T KNOW 20.2% said YES 2.5% said OTHER (e.g. confusion about regulations vs. guidelines)

Finally, we asked you to share your thoughts about the most important elements, topics, or skill areas that should be addressed in distance counseling training. Overwhelmingly, answers fell into these general categories: (a) Legal/ethical and privacy/security issues, (b) techniques/ skills unique to distance counseling, and (c) technological skills and ability. With respect to future research, the majority of respondents indicated a desire to have more research on the efficacy of online therapy, including which client populations could benefit the most from this method of treatment.

With regard to the practice of online therapy, we asked practitioners about the ethical codes to which they adhere. The results are displayed in the illustration. It should be noted that so many different ethical codes were mentioned in the “other” category, that they are too numerous to name. These ethical codes were usually industry or state specific T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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We invited you to share any last comments and here is what some of you said: • “Online practitioners should be encouraged to become researchers too - we need this!” • “It's all a work in progress with many unknowns yet there are people delivering services without considering ramifications of what they are doing. I think that without some level of training on the topic it's like an accident waiting to happen.” • “Psychotherapists and counsellors need to be not only accredited but they should have practiced a while before embarking on online therapy. It takes skill to do deep work online.” • “After my initial doubts I now love being an Online Therapist!” The results of this informal study reveal some important trends occurring in the field. Although many respondents view legal/ethical issues and security/privacy concerns as an important aspect of distance counseling training, many practitioners do not even use encrypted technologies to communicate with their clients. We crossed tabulated those who have been trained in online counseling with those not using encryption, with the following results (trained practitioners in orange). The chart demonstrates the importance of training with respect to understanding privacy and security issues. This difference is most clearly reflected in the finding that 43.9 % of untrained practitioners do not use encryption, whereas only 21.4% of trained practitioners do not use encryption. Such an increase in compliance with encryption technology is significant and underscores the effectiveness of such training. It should be noted, however, that the majority of respondents are referring to Skype, which while being an encrypted service, is not HIPAA compliant 66

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(see here for more resources on this). This is an important distinction for those practicing in the USA. The issue of practicing outside one’s own state and country also raises legal and ethical concerns.

In the meantime, as this field continues to evolve, those who practice online therapy will be responsible for shaping its character and refining its quality. With continual research and a commitment to high standards of practice, the challenges faced by today’s pioneers may one day inspire the best practices for tomorrow’s practitioners. Historically, most therapists shy away from utilizing any new technique or device until proper training has been received - even customer service agents receive training on how to communicate effectively, and yet, our profession seems not to be motivated to be trained with technology. We had to learn how to use proper “counselling-speak” with our mannerisms and our voices when physically present - does it not stand to reason we need to do the same using different methods to communicate? n


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Cyber Supervision Anne Stokes

As I sit here at my laptop a few days before Christmas, my thoughts are turning away from the grey skies and early twilight here in England, and going towards 2012. I’ve just been jotting and doodling about what I might like to change in my life as an online supervisor. Even though you will be reading this almost a month into the New Year, I have decided to share my thoughts with you. At first, they seem frivolous and the writings of someone who badly needs the Christmas break, but underneath, there are some more important ideas about working online. If you are an online supervisee, rather than an online supervisor, I am sure you can change these slightly

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to see how they would fit life as a supervisee too. So, here goes! How it’s going to be in 2012 J 1. I am going to avoid ‘just having a quick look’ at my supervision emails at 11pm. It’s never a quick look and I am fooling myself! There is always something that I choose to read, and sometimes I can’t get it out of my head when I eventually do get to bed. 2. I will stop myself looking in my inbox five minutes before I am due online for a live supervision session. It takes me away from my preparation for that supervisee, and distracts my thinking about what

we might be working on together, or where we ended last time. I wouldn’t do this if they were f2f supervisees, so why do I do it here? 3. Maybe I don’t need to be quite so addicted to backing everything up…… you can have too many external backups….. can’t you?? 4. I will remember that I am a role model for my supervisees (Oh, that feels terrifying! Who - me?) Perhaps that way I will manage not to be a workaholic, since I am always telling them to get the balance right between work and the rest of life. 5. I will set time aside in my


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New Year's Resolutions of an Online Supervisor diary to trawl for new information and research about online supervision. And when I have found it, maybe I will also read it! 6. I will go back and revisit the websites that I pass on as information to supervisees to help support them and their clients. Do they still exist and are they still relevant? While I am about it, are there new ones that are as good or better? 7. I will make contact with the managers of the organisations which have contracted with me to provide online supervision of their counsellor(s). Most don’t seem to want this and would rather I stay silent, as if I didn’t exist. However, I do have accountability towards

them, so some occasional contact feels ethical. Note to self – if I succeed in 5, 6 and 7, am I negating resolution 4? Oh dear, these resolutions are a minefield! 8. I will be more professional in charging for all those ‘odd bits’ of time I spend on organisational matters for online supervisees. Their organisations may not like it, but I am sure my accountant will! 9. I will stop to think before I say yes. That means taking time to think whether I have the space and energy to take on new work, even though I know I would love to do it, whatever ‘it’ may be. Alternatively, I might think what I can drop to take on

something new. Now that’s a novel idea. 10. And when I have achieved all of the above, I will sit back and polish my halo. I’d probably be unbearably smug if I managed it all, but to turn the old saying on it’s head, ‘If a job’s worth doing, its worth at least trying, even if the result isn’t perfect!’ So, a little belatedly, I wish you a very good 2012, in which you achieve some of the things you want to do to make sure you enjoy your online supervision and your non work time. Anne Stokes is based in Hampshire, UK, and is a wellknown online therapist, supervisor and trainer and Director of Online Training ltd.

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Ne wInnovations Facebook Takes Bold Steps In Healthcare Samantha Murphy Last month, Facebook took a bold step into the healthcare world and launched a new initiative connecting suicidal users to national hotline crisis counselors at their precise moment of need. This new service adds to a list of prosocial programs incorporated by the social networking giant in 2011 including an aggressive crack-down on hate speech, bullying and anti-gay propaganda. At a time when it seems that not even a month goes by without another journalistic story of a high profile Facebook-announced suicide, this new service hasn’t come a moment too soon. According to Substance Abuse and Mental Health Services Administration (SAMHSA), there are almost 100 suicides a day, and in the past year over eight million people over the age of 18 had seriously considered suicide. 70

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But despite its clear altruistic intent, Facebook’s new service has been met with mixed reviews and perhaps for good reason. Here’s how it is supposed to work: if Facebook users notice that one of their friends has posted a suicidal statement, they may click “report” and notify Admins of the issue. Presumably, this report is quickly screened for legitimacy and then almost immediately, Facebook Admins send the user an email with an invitation to call the National Suicide Prevention Lifeline and a link to a private web chat with one of the Lifeline crisis counselors. At face value, this initiative seems like a step in the right direction. “The science shows that people experience reductions in suicidal thinking when there is quick intervention,” said Lidia Bernik,

associate project director of Lifeline. “We’ve heard from many people who say they want to talk to someone but don’t want to call. Instant message is perfect for that.” Indeed the comfort allowed by communicating via chat is among the online counselor’s most powerful advantages, and for the perpetual ‘netizen’, such as gamers, social media users, and a large percentage of adolescents and teens, crisis counseling by instant message may prove to the best way to “meet them where they are” both literally and figuratively. But not everyone had stars in their eyes and a sigh of relief when they heard the news. Psychologist John Grohol blogged that he was concerned about the “slippery slope” created by the initiative, citing privacy as his primary issue with the plan.


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In most cases, Facebook and Lifeline are probably correct to assume that the email address used is private, but what about the cases where the account is shared or monitored? Says Grohol. “Suddenly [a] thirdparty knows about the suicidal person’s health status without their consent.” Though Grohol did agree that desperate times call for desperate measures and in life-threatening situations such as these, he worried that Facebook’s unilateral decision to breach a user’s privacy created an uncomfortable “Big Brother” situation. “If an email

is okay to save someone’s life, why wouldn’t it be okay to try and stop people from engaging in unhealthy (even life-threatening) behavior in general?” asked Grohol. The legal and ethical implications of the program are vast. Are we ready for a social network company to mediate some of the most vulnerable private moments in our lives? How long will it be until we see our first court case against a Facebook user who commented on a suicidal status but failed to report it? That is, if they could figure out how.

For me, the most pressing issue with Facebook’s suicide prevention initiative is a more practical one. Though I have plenty of daft moments, I consider myself to have an above average amount of Facebook acumen. That is, I can find my way around, I can create and maintain large groups, I can change my privacy settings with relative ease, and I can hide an annoying or offensive status with ninja-like precision. But tasked with reporting a suicidal statement, I found myself completely and utterly baffled. First I couldn’t find the “report” button. When I did eventually locate the button, which sometimes masquerades as an “x” in the upper right hand corner of a post in new timeline-style layout, I was asked if I wanted to “Report/ Mark as Spam…” I don’t mean to be pedantic, but in an urgent moment where someone’s life is on the line, it would seem to me that the reporting process should be streamlined and not so easily confused with reporting spam. Continuing along, more curious than confident, I clicked this link anyway. The status message I was reporting T I L T M A G A Z I N E Jan u ar y 2 0 1 2

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Ne wInnovations continued out that they could do this at all. Clearly, program awareness was an issue.

was immediately replaced by a box that thanked me for my help and feedback. (Huh?) It offered that I could either undo this action—apparently the link is reported as spam automatically—or report it as abusive. Neither was correct and neither seemed to offer me a way to report a suicidal expression. This was taking too much time. It is worth stating here that if one were friends with the suicidal user in real life as well as on Facebook, it would be most prudent to call emergency services first and perhaps attempt to use the Facebook system afterwards to cover all bases. In this day, however, it’s not uncommon to have Facebook-only friends that may not know the details of your location and thus, Facebook’s reporting system would be better than nothing. 72

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So, I clicked report. This gave me a dialogue box (below) with a series of multiple choice answers about why I was reporting the post. If one chooses violence or harmful behavior, they’re given a drop-down box that includes self-harm and suicidal content. Finally, more than 5 long, confused minutes later, I was able to report the issue. I don’t know how long it would take until actual contact would be made with a crisis counselor, but it is worth further research (Facebook was not available for comment.) Others weren’t so diligent. I posted a dummy suicidal status and I asked four Facebook literate colleagues to tell me the process to report a suicidal statement from my page as fast as they could. Every single one of them was surprised to find

When I insisted that it could be done over the balks and blank stares, not a single one of them was able to do it without using the search box, which led them to a completely different box (see illustration). They all got stuck at various places in the system and only one of them found the violence and harassment box at all. Although the system needs work and its implications may be as far-reaching as its potential, it’s hard to argue that Facebook’s new suicide prevention initiative makes it much more likely that being just a couple of clicks from a stranger might just save someone’s life someday.

Samantha Murphy is a former psychotherapist turned freelance psychotech writer based in "Silicon Pastures", aka, Lancaster, Pennsylvania. She discusses all things psychology, technology, and bacon-related at @smanthamurphy.


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TILT – Therapeutic Innovations in Light of Technology

Marketing Toolbox

Susan Giurleo

The other day I had a friendly debate on my blog with a colleague who stated that marketing can take many forms, but the real crux to building a practice is being a highly skilled therapist. While I agree that being excellent at your work is of paramount importance, I disagree that it is the only factor that matters as we build our businesses.

“Eight-in-ten internet users look online for health information, making it the third most popular online pursuit among all those tracked by the Pew Internet Project, following email and using a search engine. Since one-quarter of adults do not go online, the percentage of health information seekers is 59% among the total U.S. adult population.”

Marketing matters. And for therapists who want to work online, online marketing matters more. Why? To work via the internet you need to connect with people comfortable using technology and the internet. The only way these folks will find you is if you stand out in a crowded online environment. This sounds basic and simplistic, but when I talk to therapists who are looking to offer services online, they struggle with developing a robust online marketing presence. And these people are online in big numbers. In February, 2011, the Pew Research Center published statistics on how the public is utilizing the internet to access health care information. They found:

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And statistically, • 66% of internet users look online for information about a specific disease or medical problem (perennially in the top spot). • 44% of internet users look online for information about doctors or other health professionals.


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Why Online Marketing Matters What this means for you: a lot of people are searching online for health care professionals. Marketing online makes sense. Finally, I have a very specific philosophy about marketing online. I want all mental health professionals and coaches to market so that we can educate and inform the general public about their emotional health. Robust marketing is sharing useful information that allows us to demonstrate our expertise and allow others to get to know, like and trust us. Once they understand what we do and how we can help, they will be willing to engage with us and invest in our services.

that contains more useful, helpful information to the folks who have already trusted you with their email address. • Be present on social media, especially Facebook and Twitter. • Engage with people, be a resource (you do not need to offer any therapeutic or specific clinical information in social media to be helpful and seen as an expert). • Repeat For the online therapist marketing online isn’t something nice to do. It is part of the core of your business.

How to market online? I’ve shared some tips on how to market online in previous TILT articles, but here is a quick review: • Start with a professional website and blog • Write blog posts at least once a week • Offer a free educational report or audio/ video series that people can download once they give you their email address.

ABOUT THE AUTHOR Dr. Susan Giurleo is a psychologist who blogs about health care, small business and social media marketing at http:// drsusangiurleo.com. You can connect with her on Twitter at @SusanGiurleo

• Send a weekly or bi-weekly email newsletter

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TILT – Therapeutic Innovations in Light of Technology

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TILT – Therapeutic Innovations in Light of Technology

“The world was hers for the reading.” ~Betty Smith, A Tree Grows in Brooklyn

Love For the

Books of

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Social Media for Coaches: Strategic Communication Online Marilyn McLeod Coaching is a growing industry with many life coaches, business coaches, and executive coaches starting their own small businesses. Business marketing is important, and especially for small business, social media can be very useful. Because social media is all about relationships, social media and coaching are a natural fit. Marilyn’s book takes the reader through her own coaching process to help coaches find their sweet spot in social media.

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Stay tuned next issue for... 99 More great articles about online coaching, online therapy and related topics! 99 As always, we will feature our regular columns about ethics, research, law, film, marketing and technology! 99 If you are interested in submitting an article, review our author guidelines at www.onlinetherapymagazine.com 99 If you are interested in advertising in an upcoming issue, email advertise@onlinetherapymagazine.com