TILT Magazine Issue 14

volume 3, Issue three Spring 2013

The Use of Avatars

From Storytelling and Metaphors To Social Skills and Bullying PAGE 22 and PAGE 32

PAGE 15

Online Therapy and Patient Engagement PAGE 43

Skype & HIPAA: The Vexing Question PLUS...

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 3, Issue 3, spring 2013 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 Jay Ostrowski Associate Editor for Supervision Anne Stokes Associate Editor for Marketing and Practice Building Clinton Power Associate Editor for Film and Culture Jean-Anne Sutherland Resident cartoonist Christine Korol 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 15 Online Therapy and

Patient Engagement

22 Unlocking the Client's

Internal Dialogue with Virtual Worlds

32 Social Skills Groups in the Virtual World

43 Skype and HIPAA:

The Vexing Question

Issue in every

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News from the CyberStreet

10 Research Review 20 Wired to Worry 30 Reel Culture 36 Student Spotlight 38 CyberSupervision 40 New Innovations 48 Marketing Toolbox

52 For the Love of Books 54 Advertiser’s CyberMarket

A Note from the Managing Editors…

Welcome, or welcome back, to TILT – Therapeutic Innovations in Light of Technology, and the third issue of Volume 3.

In this issue, we have four special features for you!

David Tinker of ProReal describes their new virtual environment, which helps both therapy and coaching clients use metaphor virtually to explore issues and overcome obstacles in life. Our front cover this issue kate anthony & deeanna merz nagel with the has already given you a feel for their work. As David online therapy institute in second life tells us, “There is emerging evidence from the UK, Germany and the US that the use of virtual world technology tends to improve the therapist/client relationship. In early coaching applications using ProReal, coaches have reported their immediate and strong connection with the client’s world; this has then enabled coaching interventions using the language and symbolism which the client has selected”.

Also within the field of virtual environments, Erin Sappio writes about InWorld Solutions, which runs online social skills training programmes in schools. InWorld Solutions is a controlled virtual world to conduct therapy through role play, modelling, training, education, and simulation. The virtual world is also used in an unstructured format with students who need help processing events that have happened in their lives, which proves particularly useful for students on the Autism spectrum.

We are also very pleased to offer you a chapter excerpt from the book Engage! Transforming Healthcare Through Digital Patient Engagement, based on an interview with our very own DeeAnna.

Read more about the book and order it from our Love of Books page.

Our fourth feature is about the ongoing vexing question of Skype and HIPAA. We are pleased to welcome this valuable article from Rene Quashie, who is Senior Counsel in the Washington D.C. office of Epstein Becker and Green and also a member of the Legal Resource Team at the Center for Telehealth and eHealth Law. He notes that for telehealth providers who decide to use Skype, there are a number of considerations they should review to better protect themselves from potential HIPAA liability, and offers those considerations to readers of TILT. Our aim continues, issue by issue, to keep you up-to-date with developments in innovations in service delivery. In particular, the Cyberstreet is about what is new and noteworthy at the Institutes as well as with our new graduates, supporters and partners.

All our other regular columnists are here, with useful and entertaining comment on research; marketing; legalities; innovations and CyberSupervision. In particular this month, we welcome the experiences of Jane Fahy of gamblingtherapy.org, who is completing her Specialist Certificate in Cyberculture: Online Therapy as part of the organisation’s service development.

And of course there is a good dose of humour from our resident cartoonist, Christine Korol. We hope you enjoy this issue, whatever professional world you inhabit. J

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NEWS CyberStreet

TILT – Therapeutic Innovations in Light of Technology

from the

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online program that qualifies toward the Board Certified Coach Credential as well. Here’s where to find out more: http://onlinetherapyinstitute. com/certified-professional-coach/

News from the Training Room!

We have launched a new list of Specialist Certificate Tracks- areas of specialty or concentration! Why? Because people have asked us for our core training tailored to a specific audience, so we took the most requested topics and a few of our personal favorites and created new offerings!

Each Track consists of 30 hours of course work.

The pre-requisite for these varying Tracks is a 30 hour Foundational Cyberculture Series.

View the list here and let us know what is most interesting to you!

• Online Therapy • Online Coaching • Online Supervision • Avatar Identities • Human Resources • Peer Support • Children & Youth • Cultural Arts • Dystopian Studies • Intuitive Studies Be sure to check out the details here: http:// onlinetherapyinstitute.com/online-training/ Our Certified Professional Coach Training is gaining traction so if you are looking to become a credentialed coach, we offer an

Course Discount!

Our self- directed coach courses are a big hit at the Institute for Life Coach Training (ILCT)! (AND they qualify toward the ICF self-directed allowance for coursework!)

See our ILCT offerings! Purchase through ILCT and receive $25.00 off! Use Coupon Code TILT (offer ends June 1, 2013). http://lifecoachtraining. com/index.php/programs/ self_directed/

In other training news...

Where are we facilitating workshops live?

Check out our Upcoming Events! http://onlinetherapyinstitute.com/events/ DeeAnna is facilitating Distance Credentialed Counselor trainings in: August 22, 2013 University of Phoenix - Washington, DC September 12, 2013 University of Phoenix - Orlando, FL September 19, 2013 University of Phoenix - Schaumburg, IL

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October 10, 2013 Ridgeview Institute - Smyrna, GA November 6, 2013 University of Phoenix - Philadelphia, PA For details check out: http://www.readyminds.com/training/dcc_event. asp Or email: ReadyMindsTraining@phoenix.edu

Media, Publications & Blogs Kate was the subject of Coaching Today's "In Focus" feature, describing how her career started and developed, and about her role as Executive Specialist for Online Coaching for the British Association for Counselling and Psychotherapy's Coaching Division.

Kate and DeeAnna published Appreciating Cyberculture and the Virtual Self Within in Self & Society, the Journal of the Association for Humanistic Psychology.

Clara Lang, the fictitious therapist featured in our book, Therapy Online: A Practical Guide, is now featured at www.claralang.com. Her blog features posts by Online Therapy Institute’s Specialist Certificate students. Check out her website and blog!

Stay tuned! LoriAnn Stretch has joined Kate and DeeAnna in editing a new textbook: The Use of Technology in Clinical Supervision and Training: Mental Health Applications to be published late 2013/ early 2014 by Charles C. Thomas Publishers.

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Join our community Find out all the ways to join our community by checking out our community page! http://onlinetherapyinstitute.com/community/

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Research Revie

Psychoa Environm R

eaders of this magazine will be familiar with the idea that a range of online environments have significant psychoactive components. This article summarises a few examples of recent studies that exemplify the power and reach that the online world can have, both positive and otherwise.

A multi-centre study of the relationship between exposure to violent computer games and cyber-bullying (Tam et al, 2013) found that those who played computer games with significant violent elements were twice as likely to be victims of bullying online and four times more likely to mete out bullying themselves. As the authors note, ‘exposure to violent online games was associated with being a perpetrator as well as

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a perpetrator-and-victim of cyber-bullying’. A reverse correlation is possible, in this instance, and those already more prone to involvement in bullying (whether as victim or perpetrator) may have been more likely to choose violent games, both possibly being related from preexisting personality or cultural traits, so this study alone does not confirm whether playing violent computer games actually causes increased bullying behaviour although it is supportive of a clear connection between the two. It is part of the accumulating evidence that exposure to violence online may have a toxic psychoactive component and, especially when seen in conjunction with other studies, is worthy of note particularly by parents, policy makers and gamers themselves.

Becker et al (2013) found that multi-tasking with media – using several forms of media simultaneously or in rapid sequence – is significantly associated with depression and social anxiety. Again, reverse correlation is a possibility leaving the direction of causality unconfirmed, but the authors suggest that multi-tasking with media may in itself represent a specific risk factor for mood and anxiety

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ew S t e p h e n G oss

activity in Online ments disorders and that future research should take this into account.

Undesirable psychoactive effects, however, are but a small part of the story and desirable impacts are more frequently reported in the peer reviewed literature and there is already a clear body of evidence that supports benefits of a range of technologies when designed and deliberately used in pursuit of mental health benefits.

CCBT has a long history of outcome studies and at the end of 2012 Powell et al, for example, reported further encouraging findings for MoodGYM, one of a growing number of such tools, with a large sample of 3070 participants.

Significant improvements in mental wellbeing were found among MoodGYM users in comparison with a control group (who began with equivalent levels of depression and wellbeing) on a range of measures. An intriguing aspect of the study was a large drop-out rate among those who used MoodGYM (75% of whom did not complete the study, contrasting with only 27% of participants in the study who did not use it). This may suggest that those

who found the process agreeable were more likely to continue, possibly confirming the view that technologies have great potential but simply are not for everyone. The authors in this study note strong potential for widespread benefits from the use of properly designed and tested products.

Kenter et al (2013) reported on the acceptability and effects of an online, guided, problem-solving treatment offered to clients referred for depression, anxiety or burnout at a clinic for use during the lengthy waiting period that often occurs. A little over half of those offered the chance to take up the online service did so, again showing that technologies are not everyone’s preference even when the alternative is to have to wait for routine treatment to begin, but the authors also stress that this level of take-up also demonstrates a significant level of acceptability. The authors note that ‘those who accepted the online treatment were more often female, younger and lower educated than those who refused’, contrary to the prejudice that still survives in some parts of the profession that technologies are particularly suited to reaching men or that they present a barrier to anyone without high educational attainment. Those who took up the chance to work online, however, showed large improvements for depression and anxiety (though not burnout), while those on the waiting list did not. The difference between the groups disappeared once everyone had begun face to face therapy some weeks later. Overall,

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Research Review the findings suggest that the online provision offered faster rate of recovery - a ‘head start’ for those who were willing to make use of the opportunities afforded by the technological option.

Giroux et al (2013) reported that virtual reality exposure therapy in the treatment of problem gambling was viable but requires at least repeated use and, possibly, the addition of standard processes such as cognitive restructuring to be properly effective. Botella et al (2013) showed the psychoactive reach of virtual reality environments, in a preliminary report of a study of its use in conjunction with other treatments of fibromyalgia, the results showing sustained reductions not only in physical pain but also of depression and increased use of healthy coping and improvements in emotional state.

The effectiveness of the online environment for training was explored by Moskaliuk et al (2013) who found that virtual settings could not only be as effective as standard models in preparing trainees for complex tasks but, in some important respects such as knowledge transfer, even more so, emphasising their utility in training.

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

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continued

REFERENCES Becker, M.W., Alzahabi, R. and Hopwood, C.J. (2013) Media Multitasking Is Associated with Symptoms of Depression and Social Anxiety. Cyberpsychology, Behavior, and Social Networking. 16(2): 132-135.

Botella, C., Garcia-Palacios, A., Vizcaíno, Y., Herrero, R., Baños, R.M. and Belmonte, M.A. (2013) Virtual Reality in the Treatment of Fibromyalgia: A Pilot Study. Cyberpsychology, Behavior, and Social Networking. 16(3): 215-223.

Giroux, I., Faucher-Gravel, A., St-Hilaire, A., Boudreault, C., Jacques, C., and Bouchard, S. (2013) Gambling Exposure in Virtual Reality and Modification of Urge to Gamble. Cyberpsychology, Behavior, and Social Networking. 16(3): 224-231.

Kenter,R., Warmerdam, L., Brouwer-Dudokdewit, C., Cuijpers, P. and van Straten, A. (2013) Guided online treatment in routine mental health care: an observational study on uptake, drop-out and effects. BMC Psychiatry. 13(1): 43.

Lam, L.T., Cheng, Z. and Liu, X. (2013) Violent Online Games Exposure and Cyberbullying/Victimization Among Adolescents. Cyberpsychology, Behavior, and Social Networking. 16(3): 159-165.

Moskaliuk, J., Bertram, J. and Cress, U. (2013) Impact of Virtual Training Environments on the Acquisition and Transfer of Knowledge. Cyberpsychology, Behavior, and Social Networking. 16(3): 210-214.

Powell, J., Hamborg, T., Stallard, N., Burls, A., McSorley, J., Bennett, K., Griffiths, K.M. and Christensen, H. (2012) Effectiveness of a web-based cognitivebehavioral tool to improve mental well-being in the general population: randomized controlled trial.

Journal of Medical Internet Research. 15(1):e2.

Please send reports of research studies, planned, in progress or completed, to the TILT Editor at editor@onlinetherapymagazine.com

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Research Call

Call for Papers: British Journal of Guidance and Counselling: Online Practice Symposium Edited by Stephen Goss and Tristram Hooley This symposium will look at the impact of the online environment on the practice of guidance, counselling, psychotherapy and related services. We are particularly interested in receiving proposals for academic articles that will examine: • • • • • •

models of e-counselling and e-guidance practice the use of social media (sometimes referred to as Web 2.0) the role of mobile technologies how online gaming can support practice in counselling and guidance competencies, training and supervision in online guidance and counselling the interface between online practice in guidance and counselling and conventional/face-to-face delivery (and blended technologies) • the ethics of online practice • the challenges of the digital divide and inequalities in digital literacy • the research agenda in online guidance and counselling.

Proposals for papers on other topics relevant to any form of online practice are also invited. The items above should be seen as indicative, not an exhaustive list of topics.

Alongside the symposium, the editors are organising a one-day meeting on e-guidance and e-counselling to be held in November 2013. Authors who are thinking of contributing to the symposium are encouraged to attend and contribute to the meeting.

Proposals for articles for the symposium and/or live event should be sent to Tristram Hooley (if related to guidance and careers) at T.Hooley@derby.ac.uk or to Stephen Goss (if related to counselling, psychotherapy or other aspects of mental health provision) at stephenpgoss@googlemail.com. Proposals should include the title, an abstract of no more than 500 words and list of authors, including contact details for the corresponding author and should be submitted by July 2013. Full papers will be requested for submission up to January 2014 but should be submitted earlier, when possible, in agreement with the symposium editors.

For more information on the symposium and submitting your topic, CLICK HERE.

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The Use of Technology in Mental Health Applications, Ethics and Practice Edited by

Kate Anthony, MSc, FBACP

Online Therapy Institute

DeeAnna Merz Nagel, LPC, DCC

Online Therapy Institute

Stephen Goss, PH.D., MBACP

Independent Consultant in Counselling, Research, Supervision and Technology in Mental Health 2010, 354 pp., 7 x 10, 6 il., 5 tables • $74.95 hard, $49.95 paper (hard) ISBN 978-0-398-07953-6 • (paper) ISBN 978-0-398-07954-3 • (eBook) ISBN 978-0-398-08447-9

Technology is revolutionizing the delivery of mental health services. In this book, the reader is introduced to the broadest possible sampling of technologies used by mental health professionals today. It contains 30 chapters on different aspects of technological innovation in mental health care from 43 expert contributors from all over the globe, appropriate for a subject that holds such promise for a worldwide clientele and that applies to professionals in every country.

A wide range of styles is offered, from the individual practitioner exploring a new technology and writing anecdotally about their personal experience, to some of the world’s most experienced practitioners writing a thorough overview of a technology and its uses in the profession.

In each chapter, you will find introductions to the technology and discussion of its application to the therapeutic intervention being discussed, in each case brought to life through vivid case material that shows its use in practice. Each chapter also contains an examination of the ethical implications – and cautions – of the possibilities these technologies offer, now and in the future. Technological terms are explained in each chapter for those not already familiar with the field, while the content should stimulate even the most seasoned and technologically minded practitioner.

Psychotherapists, counsellors, psychiatrists, life coaches, social workers, nurses – in fact, every professional in the field of mental health care – can make use of the exciting opportunities technology presents. Whether you have been a therapist for a long time, are a student or are simply new to the field, The Use of Technology in Mental Health will be an important tool for better understanding the psychological struggles of your clients and the impact that technology will have on your practice.

Further information on ethics, training and practical exploration of online therapy can be found at: www.onlinetherapyinstitute.com, whose work extends and deepens the resources made available in this volume.

5

easy ways to order!

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• books@ccthomas.com

Books sent on approval • Shipping charges: $7.75 min. U.S. / Outside U.S., actual shipping fees will be charged • Prices subject to change without notice

Online Therapy

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&

Jan Oldenburg

Patient Engagement Before DeeAnna Nagel began practicing online therapy, and before she co-founded the Online Therapy Institute, she was a patient, and an e-patient. In early 2000, she was nearly incapacitated with a mysterious lung disease. Her This article is a chapter excerpt from the book medical journey took her from Engage! Transforming Healthcare Through Digital specialist to specialist, each Patient Engagement, based on an interview with DeeAnna Merz Nagel. Read more about the baffled about her symptoms, book and order it from our Love of Books page.

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while she got sicker and sicker. She discovered an online forum for lung disorders, where she found a disease that matched her symptoms and information about the tests that would prove it. She went to her doctor and explained what tests she wanted and what disease they were testing for. Her doctor was skeptical and patronizing, but did the tests, which confirmed the diagnosis of sarcoidosis Ms. Nagel had found through the online forum.

During the next year, Ms.Nagel was unable to work outside of her home while she recovered from her disease. She began working as an online therapist with eClinics, Help Horizons, and Here to Listen, all arranged so that a therapist can make him/herself immediately available to a client for drop-in chats. With the benefit of hindsight, Ms. Nagel noted that these are not recommended conditions for an e-therapy relationship, as it means you are doing triage with a patient before you are established as a trusted and contractual clinical relationship.

As a result of this experience, however, Ms. Nagel became intrigued by the opportunities for online therapy, but also was deeply aware of the need for an ethical framework that would

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What is an e-patient?

We who’ve become e-patients don’t wait for our providers to tell us everything; we get it in gear, we ask questions, we do what we can to help.

Don’t think you’re qualified? Consider the advice on the magnet at right: Trust yourself.

You know more than you think you do.

Radical new advice? No, it’s the opening line of Dr. Spock’s Baby and Child Care, first published sixty years ago, in 1946. ~Dave deBronkart widely known as “e-Patient Dave” Excerpted from http://epatientdave.com/for-patients/

govern its practice and the use of online tools within a therapeutic framework. Peers from the International Society for Mental Health Online came out with a set of original guidelines in 2000, but Ms. Nagel and colleagues felt there needed to be more. The American Counseling Association (ACA) issued their last code of

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What is Sarcoidosis?

Sarcoidosis (pronounced SAR-COY-DOESIS) is an inflammatory disease that can affect almost any organ in the body. It causes heightened immunity, which means that a person’s immune system, which normally protects the body from infection and disease, overreacts, resulting in damage to the body’s own tissues. The classic feature of sarcoidosis is the formation of granulomas, microscopic clumps of inflammatory cells that group together (and look like granules, hence the name). When too many of these clumps form in an organ they can interfere with how that organ functions.

For more information, visit the Foundation for Sarcoidosis Research.

ethics in 2005. While the code covered most issues related to online therapy, there have been significant changes in cyberspace with the advent of Web 2.0. For example, social media was not fully in existence in 2005 and, therefore, the ACA code did not address how social media can impact a therapist’s work and professional presence. Their next code of ethics will not be issued until 2014. To fill the

gap, Ms. Nagel and a colleague started the Online Therapy Institute. They created a set of guidelines and issued them as a starting point for others practicing in the field. Ms. Nagel is clear that the standards of practice are still evolving and will continue to change as practices and technologies to support them continue to evolve.

Many therapists who practice in traditional face-to-face settings are finding that communication that formerly happened by phone or in the context of a session has moved to email. As a result, they need to determine how to weave online tools into the fabric of face-to-face practice. The American Psychology Association’s (APA) Center for Workforce Studies conducted a study that showed that overall email use with clients for service delivery more than tripled among practicing psychologists from 2000 to 2008, with approximately 10% of those sampled using it weekly or more in 2008. Practitioners’ use of videoconferencing with clients, while still rare, increased from 2% to 10% among survey respondents during that same time period (Novotney, 2011). This brings a host of both opportunities and problems. Even therapists who do not think of themselves as practicing “online therapy” need to determine such things as when an email exchange becomes an e-visit and requires payment, when an issue can be addressed by email and when it

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needs to come back into a session, what their response time to emails will be, and how they set boundaries and expectations when email is a part of the therapy mix. An online code of ethics needs to address these types of issues both for therapists who use online tools as an adjunct to their practice, and for those who primarily practice using online tools.

What does online therapy look like? It can take many forms and both therapists and patients gravitate toward the mix that fits them best. Ms. Nagel loves written language and believes that writing can be a powerful healing experience for patients, so she gravitates toward email and chat. She notes that for her patients the experience is rather like keeping a journal, but with a listening ear on the other side. Her Employee Assistance Program (EAP) work is

all email-based. Sometimes her face-to-face clients will see her online, so online therapy becomes an adjunct to in-person consults.

She uses video conferencing, chat, email, and phone in her work. For her, personal video is the least-preferred option, in part because the still- jerky head movements and lack of direct eye contact make it difficult to “read” her clients.

One of the important lessons that Ms. Nagel has learned is that whenever technology is a part of the mix, there will be glitches. The problems may be as diverse as emails that are lost in cyberspace, chat or video Internet connections that don’t work when they need to, messages that are garbled because of fat fingers on the keyboard or inappropriate autocorrections, simple misunderstandings based on the written word, or timing issues based on asynchronous communications. Therapists need to prepare themselves and their patients for these kinds of problems and create back-up plans to address them. Technical problems cannot entirely be avoided, but a clear communication plan and agreed-upon strategies for dealing with problems will go a long way toward mitigating their effects.

Ms. Nagel believes that several things are required for e-therapy to become more mainstream. One is a reimbursement model that consistently acknowledges and enables payment for therapy using online tools. She

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suggests that additional studies comparing the effectiveness of online therapies to inperson therapies will be required to create the impetus for a consistent reimbursement model and consistent way of coding for online therapy. Several studies and meta-analyses have shown that the outcomes are the same or better than in-person approaches and that it can be delivered at lower costs. Her fear, however, is that as it becomes mainstream, organizations will expect therapists to use online tools without any training or guidance.

Ms. Nagel is advocating for a continuing education requirement that involves taking a course that will provide guidance about online therapy and teaches therapists an ethical framework for online engagement.

The other dimension that Ms. Nagel suggests will be required for online therapy to become mainstream is more and better tools. Advances in secure person-to-person video will certainly enhance the options available to therapists and patients alike. She and her colleagues dream of online therapy tools that will create a multidimensional experience, in which patients could securely send and receive messages, watch a video, post pictures or status updates, and perhaps interact with other patients.

Ms. Nagel also notes that there is tremendous research and energy going into exploring Avatar therapy and the use of virtual worlds for therapy. She notes that the Online Therapy

Institute does a monthly meeting in Second Life, and that InWorld Solutions has a Health Insurance Portability and Accountability Act (HIPAA)-compliant platform for virtual world therapy. However, as she notes, many therapists feel like “digital immigrants” struggling to make sense of their options and how to interact in a virtual world. The capabilities are easier for 5 year olds to use than 55 year olds, and full adoption may need to wait until the next generation comes of age.

The potential is huge for online therapy to become an effective tool for delivering mental health support to a broad audience in a cost-effective way, and it is well- worth an investment in technology, training, and ethics to achieve the potential. n

ABOUT THE EDITOR Jan Oldenburg is the primary editor of HIMSS’ Engage! Transforming Healthcare through Digital Patient Engagement (2013) and is Vice President, Patient Engagement in Accountable care Solutions from Aetna. Read an interview with Jan about the book here!

REFERENCE Novotney A. (2011). A New Emphasis on Telehealth: How can psychologists stay ahead of the curve – and keep patients safe? Monitor on Psychology. June 2011; Vol. 42, No. 6.

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WIRED TO WORRY

Guilt-Free Pleasures B

y the time that most people start therapy they have been struggling for some time with their concerns.

Many have Googled their symptoms, read self-help books, or tried medications. Most are exhausted from working so hard on getting unstuck on their own.

Christine Korol

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In the first session, I always ask my clients what they like to do for fun. Usually, they are too busy for fun.

Sometimes, with some

gentle coaxing, they timidly tell me how they spend their free time because there is so much guilt about having nonproductive, mindless fun.

In recent years, I’ve gotten in the habit of helping people create room in their lives for the hard work of therapy, but most importantly, time for their guilty pleasures. I start by having clients review their to-do list and either eliminate or brainstorm shortcuts for the things

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they hate doing. Once we have some breathing space, we add more fun into the program.

The most important thing is that the chosen activities are done without guilt! If you like dogs, watch videos of cute dogs. If you want to paint, by all means, paint.

If you want to rock out to your favorite 80s hair band, I can’t say that I share your

passion, but I do respect it. Please, feel free to ROCK OUT guilt free!

we unplug from them and focus our attention elsewhere.

These pleasures make life worth living and when we indulge in them they give us the much needed energy boost that we need to face the problems that remain. Ironically, the solutions to those problems frequently pop into our heads when

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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Unlocking the Client's Internal Dialogue with Virtual Worlds 22

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TILT – Therapeutic Innovations in Light of Technology

INTRODUCTION “The overwhelming finding was that technology and cyber communication has not only ‘‘crept’’ into traditional social work practice but, indeed, signifies a turning point” (Mishna et al, 2012). Whether we like it or not, technology touches almost every aspect of our lives and has become an essential relational medium for social and professional use. Coaching and therapy is increasingly delivered remotely, due to the demand for less travel and improvements in the capability and quality of the supporting technology.

ProReal is a new, purposebuilt virtual reality platform for therapists and coaches who want to work remotely with clients. In addition to the remote working capability, it adds to the therapeutic process

with a dynamic and creative visual representation of a client's inner and outer world.

In this article we describe the thinking behind the design, the applications for therapeutic use and the potential benefits for the therapeutic relationship.

Design The ProReal platform was originally designed to apply 3D virtual world technology as a basis for remote working in

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sociodrama and psychodrama.

The initial design was then further enhanced to include a ‘landscape’ and props as opportunities to explore metaphor and symbols.

Building on the considerable body of research on therapeutic landscape, the decisions on the setting were important.

The current landscape has a number of features taken from classic story symbolism and includes roads, mountains, a ravine, a river and a castle.

Each feature has meaning;

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for example mountains represent our higher goals and aspirations, while gates signal key moments or rites of passage. We’re familiar with these metaphors and symbols as we refer to “the crossroads in my life” or “an uphill struggle”.

ProReal is considering whether future developments to the virtual reality landscape would include more familiar settings, for example by including a home, street or office space.

This approach would give a more literal space in which a client can express and inquire;

however this would make the unconscious levels of story and metaphor less accessible in a visual form.

The use of avatars was selected in order to provide a level of “association” with the client’s world. The avatars in ProReal are plain and androgynous to enable the client to project their reality onto them. The considerations associated with this approach, compared with options for male or female avatars, are complex.

Gender-specific avatars require

clothing and therefore can bring meaning that might influence the response in the client. Our experience is that clients quickly develop a strong sense of association with these avatars and engage their own sense of identity for each avatar.

Similarly, the location of the avatar in the landscape can trigger an emotional response, for example when nearing the edge of a ravine.

To enable a client to connect and project a useful degree of reality to an avatar, there are

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each can be given a speech caption, size and colour – they travel with the client as if attached.

additional options to represent levels of authority, attitudes, emotion, thought and speech.

Avatars are given a colour which helps with identity and is part of meaning making.

Each avatar can be sized, which enables the client to visually represent the importance, authority or perceived power.

Avatars are given a posture to represent an attitude or emotion. These postures form a useful role in creating the client’s reality and in making the conversation about emotions

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more accessible. Thought and speech bubbles can be ascribed to any avatar and are designed to represent the essence of that avatar’s thinking, judgement, or intention.

Internal monologue, or “inner voice”, is represented by headlike figures behind the client avatar’s head. These voices are the parts of the client that are ever present and influential.

In the ProReal world only the client’s inner voices are represented (up to four) and

Ease of use was an important design criterion. The user interface is simple and intuitive, to support a client’s flow of expression and avoid any barriers caused by complex option selection. As the first 30 minutes represent a key phase of engagement, the client is encouraged to make early decisions in avatar selection, movement and scene creation.

The design is based on a clientcentred approach, i.e. the therapist is encouraged to allow the client to take control of the platform whilst supporting with questions and prompts as part of the therapeutic process.

To build further reality and texture into the client’s world, the platform provides options to include a number of props.

The value of these props becomes clear as we listen to language: the ‘elephant’ in the room; the ‘wall’ between people or groups; the ‘bomb’ about to go off; the ‘key’ to solving a problem. The props can be placed anywhere in the world and named, to help bring to life more of the texture

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and complexity of the story or drama. The fast-turning hands on the clock face prop have been known to give clients goose bumps!

Applications Clients can select a part of the landscape where they feel comfortable, or which represents their current situation. One client placed himself in the river with his family split on opposing banks.

This act alone opened up a

useful exploration of the reality of his home situation. Roads can be used as timelines and give the client an axis to move back and forward in time.

In a similar way to a therapist’s use of ‘Small World’, a client can select avatars to represent people, entities, external stakeholders or sub-egos.

To enable the sociometry to become visible, the avatars can be positioned anywhere in the world and face any direction. In its simplest form, a client will position a number of avatars relative to each

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Management system has been designed to ensure appropriate security and confidentiality; for example, the therapist creates an individual session which can only be accessed by one client and this process, and access to the system, is password protected. Data protection and security was of critical importance in the architecture of the system.

other, to represent a family or organisational situation, with the closest relationships next to one another and the most distant individuals further away, thus mapping out a system.

The ways in which the world can be viewed are important as they enable perspectives on a paradigm. The design here was informed by Moreno’s work and, in particular, the value in seeing the world from another’s perspective to build empathy. The platform enables the client to view the world from both first and third person, thus broadening the options for perceiving. In addition the world can be viewed from a free camera; this means the client can step away from the system

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and view it from above (or indeed from any angle) to gain a different perspective. The purpose of this is to encourage new thinking, inspired by fresh ways of seeing things. One client has commented on the feeling of being able to ‘fly’ away from self and view the world from above.

The client’s world can be shared either in person, or remotely, with a therapist or coach. The remote working function enables the therapist/coach to work with clients anywhere in the world. A client world in ProReal can be saved and returned to at a later session. It can also be accessed separately by the client, should personal reflection be valued. The User

What we are learning We’ve noticed that young people readily engage with this approach. Early feedback gives us confidence that it will help some to overcome the potential stigma associated with talking therapies. As with any new technology, there can be resistance to working in this way for some, as they may not feel confident in their computer skills and/or may be challenged by the notion of play and story-making in a strange environment.

There is emerging evidence from the UK, Germany and the US that the use of virtual world technology tends to improve the therapist/client relationship.

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In early coaching applications using ProReal, coaches have reported their immediate and strong connection with the client’s world; this has then enabled coaching interventions using the language and symbolism which the client has selected.

Early evidence from immersive virtual world technology is also of interest. In particular, the research work carried out in the US demonstrates compelling evidence that this type of technology is highly effective in supporting behavioural change. It concludes that when an individual makes a visual and visceral association with an avatar in a virtual world, this results in an increased likelihood of altering a prevalent, long-standing behaviour. Trials have focused on the ability to establish both a “current” and a “future” state for the client, thus enabling the client to associate any behavioural change with a future outcome.

The current version of ProReal includes enhancements which have been suggested by clients and coaches alike. The development path also includes several new features which

will further strengthen the functionality.

Conclusion ProReal offers a solution for those who wish to bring a new dimension to their work. More importantly, the software will allow clients to find their voice and to be able to explain their world in visual terms.

ABOUT THE AUTHOR David Tinker, MSc, is an executive coach living in London. He uses Sociodrama in his practice and will soon complete his diploma in Supervision with the London Centre for Psychodrama. He is Product Director for ProReal and responsible for design. For more information contact david@proreal.co.uk and visit www.proreal.co.uk

Reference Mishna, F., Bogo, M., Root, J., Sawyer, J. & Khoury-Kassabri, M. (2012).

“It just crept in”: The Digital Age and Implications for Social Work Practice. Clinical Social Work Journal. September 2012, Volume 40, Issue 3, pp 277-286.

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REEL CULTURE Jean-Anne Sutherland

“Craigslist Joe”: Technology, Community and Adventure In anticipation of our trip home to Florida and our subsequent day in the Gulf of Mexico, I decided that my daughter and I truly needed to snorkel.

The water is perfectly clear and while there are no coral reefs like those in Mexico, it’s still a stunning sight to see. Thing is, a snorkel, mask and fins are not cheap! Neither am I but, still, a budget is a budget. So I found a set on Craigslist and today will drive to the home of some strange man and buy his very slightly used fun-in-the-sun toys. If I listen to some of the masses, I should fear for my life. Surely he only says that he has a snorkel. In reality he lures people over, under the guise of snorkels, and kills them methodically. That’s the Craigslist community, right?

Nothing will serve to shatter that myth more than the documentary “Craigslist Joe.” This young man, Joe, decides to take 31 days of his life and live completely off of Craigslist. He walks away from his home with no money, no contact with anyone he knows, a new telephone number, new email addresses, a laptop, cell phone and a guy (that he found on Craigslist) to film the experience. He wants to know to what extent, in our indulgence in capitalism and technology, have we lost our sense of community. He wants to connect with people 30

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in the United States, get a snapshot of his country and use technology to do so.

I don’t want to reveal too much about his adventure, as that would ruin your experience of watching the doc. Suffice it to say that he indeed finds a community and they are full of generosity and spirit.

Over the course of the month, and using nothing but Craigslist connections, Joe is given food and a place to “crash.” He volunteers; takes dance classes; works for a bit of money. He goes to Open Mic nights in clubs. Through the “Ride Share” link, he manages to catch a lift from southern California to Portland, Oregon, to Seattle Washington, to Chicago, Illinois, to Vermont; to New York, then south to Florida, Louisiana and, back to California.

Maybe you know this and maybe you’ll be just as surprised as I was – people are more than happy to invite you into their car, not so much for help with gas money but for the companionship on a long ride.

As a sociologist, I was struck by the “types” of people that Joe encountered. With one or two slight exceptions, all of the folk that help him out are working class or lower-middle class. We don’t see a Mercedes pick him up nor a wealthy family invite him into their homes. No, the people that open themselves to him have humble abodes and cars that sometimes work and other times, not

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so much. They tend to be young, like Joe, but there are certainly the older-than-Joes that find his mission valid and moving and are more than willing to assist. And not just assist – they invite him in, tell him their stories and, offer to do his meager laundry.

Several of his companions wax philosophical about life. One driver remarks that, when you are on the road (as Joe is) “Time is out the window.”

A young woman who Joes travels with from New York to Florida remarks on how the adventure is everything – “life” is what’s important. Doing what some folk would deem “crazy” (i.e., connecting with a total stranger), most of these people are very intentional about their lives and their relationships to people around them.

Just as an aside and not to be sociologically cynical but, I could also see that he had certain advantages during his life on the road. First, Joe is a very “all-American”, white, none-intimidating young man. I wonder if a racial minority had conducted this experiment if they would have encountered such openness and welcoming.

Or a woman, or someone very clearly from the lower class. Also he had a cameraman with him – adding to the allure (and the potential to star in a documentary). That aside, his tale remains heartwarming.

When Joe meets with Craig of Craigslist, the founder of the popular website remarks that, in his experiences, “…people are overwhelmingly trustworthy and generous”. Upon Joe’s return, his mother asks if he can briefly summarize his month embedded in adventure via Craigslist. As he chokes up, the only word that comes to him is “Inspiring.” Just as Craig has observed, people tend NOT to be callous and unconcerned with their “neighbors”. Unlike the myth of Craigslist as the site for murder and mayhem, Joe discovered

BUY NOW that, no, we have most certainly not lost our sense of community. And, no, technology (at least in this form) has not created a world of isolation and suspicion.

So, as I head out in a few hours, I am not only excited that I will have a snorkel, mask and fins to take to Florida – I am also looking forward to that brief encounter we have with the people around us. If it’s like other Craigslist purchases I have made, the short exchange will include a brief talk – about the neighborhood, about where we are from, about our need/desire for said purchase. I will drive away with my fun toys and the knowledge that most of us are really nice people.

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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Erin Sappio

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he use of technology in the classroom is growing rapidly, with considerable advancement from year to year. School counselors have increased their use of technology to help students plan for and apply to college. As a School Psychologist my primary interactions with students, parents, and teachers are still face-to-face or over the telephone. Increasingly, communication with parents has occurred over email. Email consultation with teachers regarding student academic or behavioral interventions has also surged. But the newest technological advance within mental health in schools is running counseling groups in a virtual world.

During the current school year, counselors in my school district ran an 8-session social skills training program through a virtual world called InWorld Solutions.

Students with disabilities and general education students who needed social skills improvement were excited to meet with counselors in the virtual world, represented by avatars. They were eager to learn to interact appropriately and have fun while gaining new skills in this new, virtual forum.

InWorld Solutions is a software program where participants create an online avatar to manipulate through a virtual world. InWorld Solutions is a HIPAA compliant program in that only participants who have written forms of consent and are invited to participate by the facilitator can access the program. This is a controlled virtual world to conduct therapy through role play, modeling, training, education, and simulation. Participants are able to speak in their own voices and hear the voices of the other participants. The program allows for sessions to be recorded and reviewed by participants so that they can learn through real-time interaction with others as well as watch interactions and react after-the-fact.

In InWorld, students are able to change their avatar’s appearance to look as much or as little as themselves as they prefer. Students change the avatar’s clothing and add or delete preferred objects from the world as they desire.

Counselors have found that participating as an avatar increases the student interest and motivation to participate in social skills group.

Social skills lessons begin with an “ice-breaker” period. During

this time, students enter the world, greet one another, and talk about their day. They are then encouraged to play a game such as Simon Says to orient themselves to the action functions of the avatars and give students a general feel of the environment. The next phase of the session is the social skill lesson presentation and practice. As the lessons are introduced that require role plays, the students choose which world they want to act out the role plays in. For example, if the role play addresses a bullying scenario that occurred in the hallway, the students meet in the hallway in the virtual world.

If scripts are required for the role play, they are typed into an Instant Messaging box by the counselor. Students have reported that they are more comfortable role playing in the virtual world as opposed to being in person because they don’t feel self-conscious. Since most students are comfortable in the video game world, the avatars are an extension of that everyday leisure activity. With decreased inhibitions, they engage more in the activities suggested by the counselor and therefore, they can better access and participate in the target lesson. The sessions wrap up with a discussion of

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what the students learned that day and how they can apply the lesson to their daily lives.

The virtual format allows for the students to play while they learn. From time to time, the students would get distracted by the virtual world itself and disappear from the world everyone is in and a counselor may find him/her playing on the virtual playground or driving a virtual car. Typically, the students come back to the lesson when called. If they do not, they may get “banished” to the virtual desert for a virtual “time-out!” A virtual recess is

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included in social skills lessons as reinforcement for on-task behavior. This may include allowing students to race one another while driving cars, chase one another, or have their avatars perform silly stunts such as jumping around or crawling through furniture.

Meeting in the virtual world has allowed access to a larger number of students in a shorter amount of time. As a counselor, I have been able to meet with students in two different buildings in the same virtual world. Meeting in the virtual world has also

allowed interactions that may not be appropriate in a faceto-face setting. For example, having two students who had a physical altercation with one another in the same group could be stressful and uncomfortable in a face-to-face environment. Working with them in the virtual world allows students to safely resolve the conflicts.

The 8-session program that were run in the Fall of 2012 were part of a larger study comparing the effects of the social skills program implemented through a

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virtual world verses the effects of the social skills program implemented through the traditional face-to-face world. The data from these groups is still being analyzed.

However, plans are underway to administer the groups again with a social skills program focused on building empathy skills in students who were disciplined for being in violation of the New Jersey Harassment, Intimidation, and Bullying Law (NJSA Statute 18A:37-17.)

The virtual world is also used in an unstructured format with students who need help processing events that have happened in their lives.

Students who may have difficulty sequencing events or students on the Autistic spectrum who have difficulty relating person-to-person can walk the counselor through events in their lives with their avatars, allowing them enough social distance where they are comfortable, yet still socially engaging them.

Although the virtual world is new to our district, it has already been effectively implemented with a number of students. The feedback from both the students and the counselors using the program is positive. Students are excited to learn to act in a prosocial manner. Counselors do not

have to worry about wasting time settling disinterested students in order to present the social skills lessons because the students are naturally motivated to be in the virtual world. Therefore, social skills groups in the virtual world are presenting themselves to be a win-win for our school. n ABOUT THE AUTHOR Erin Sappio, Ph.D, is a New Jersey Licensed Psychologist and Certified School Psychologist, working full time in a public school district in a suburb of New Jersey for the past 8 years.

Pictures approved to be included in this article by Jeanine Miles, MS, LPC, Director of Business, Development, and Marketing for the Center for Guidance Health Network.

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STUDENT SPOTLIGHT

TILT – Therapeutic Innovations in Light of Technology

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by Jane Fahy I’d been counselling compulsive gamblers for the Gordon Moody Association for two years when I was approached about delivering support and therapy to problem gamblers online. The decision to provide online support had been taken a few years earlier on the basis that GMA had 40 years experience in the field, which not many organisations can say! So they decided to give the global online community access to their expertise and the Gambling Therapy website was born.

Now I’m no stranger to a chat room and have been known to play a fantasy MMO or two in my time but I’ll be honest, I wasn’t convinced! How could I convey empathy, compassion and understanding via a computer screen? How could I work with body language without a body to observe?

Putting my reservations to one side I logged on to GT and found a therapeutic community so rich, so diverse and dedicated that no one could fail to feel the power of digital culture at work across continents as these people held hands in cyberspace......corny right? Yup, but also true.  I was touched by the peer support I had witnessed and as I started to deliver e-mail, group and chat support I was struck by the strength of feeling I had time and time again when engaging with these people. Stranger still, they could perceive this depth of feeling and they responded to it! So I had to admit it, I’d fallen in love with online therapy....

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I would like to say here that the epiphany didn’t mean I magically became an expert in online therapy, far from it! So I reached the decision to seek training and this led me to the Online Therapy Institute. I approached my training as I approach most things, with intent to be “perfect”. Everything had to be written correctly and my interactions had to be professional and precise. But something was missing from those early interactions, and that something was ME. As with face to face therapy, the therapist is the therapy and attempts to hide behind academia just made me incongruent which as we all know is a pretty big no no.

The beauty of training online was that I relaxed into the course much more quickly than I had done in previous face to face settings. I had the benefit of being able to think through responses on forums which meant that I didn’t hold back just in case I said the “wrong” thing. If I needed help between webinars I could access that either through a quick and easy e-mail to Kate or by asking my peers on the forum. I guess the continuation of support between “classes” is one of the main benefits of studying online along with the speedy feedback received on each assignment confirming whether or not I’m on the right track.

With my new relaxed approach I quickly injected my personality back into online interactions and forged a more genuine connection with my peers. This useful lesson is one I use in client work as people often apologise in early communications for spelling/ grammatical errors. I can use my experience to educate individuals about the importance of being “real” and not sweating the small stuff

 In essence, I give clients permission to be themselves.

Through both training material and experiential learning with the OTI I have learnt that using the internet to deliver therapeutic interventions can enhance rather than detract from the process as I had initially feared. Individuals who are shy in reality can find themselves unburdened and liberated by the anonymity and freedom afforded to them in an online environment. They may fear rejection less than they would if attempting to speak to someone face to face because they always have the “log off” button if they need to remove themselves from an intense situation. Although the safety of knowing the button is there means that clients rarely use it.

There has been no other time in history when human beings have been so free to invite others into their reality, to connect at any time regardless of location with others thousands of miles away and share genuine shining moments of understanding with them. Online therapy allows client and therapist to work shoulder to shoulder each assisting the other in the evolution of online support and therapy.

I don’t know about you, but I’m pretty excited to see where this goes J See you in cyberspace! n

About the Author Jane Fahy, MBACP is Clinical Services Manager for Gambling Therapy, part of the Gordon Moody Association - www. gamblingtherapy.org

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Cyber Supervision Anne Stokes

Normally I finish writing this column at least two weeks before the deadline for submission, which gives me time to reflect on what’s been written and then get it in ahead of time. This time, while I will meet the deadline, it will be a tight run thing! The reason – a virus. No, not a virus in my computer, but one in my body J. Nearly four weeks ago, I succumbed to a horrid virus, which apart from manifesting in a cold, a cough and nausea, rendered me incredibly weak.

I am usually an extremely healthy person, so this was a new experience for me.

You may wonder why I am telling you this – what has it got to do with online supervision? Well, it raised all sorts of ethical dilemmas for me. If I had been working f2f, I would have cancelled

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supervision, as to sit with supervisees while snuffling and choking away would have been extremely distracting for them (and me) and also I would have been worried about infecting them. It didn’t feel such a straightforward decision with my online work. Was I well enough to answer emails? I was certainly able to read them, and felt that I could make my responses professionally and with the same degree of awareness as normal. But was I deluding myself? Was I in a place to be able to make that judgement soundly? At one point my temperature was 103.5, and I am told that at 104, you start hallucinating! How near to that was I? Then there were my synchronous supervisees. I did ask video and voice supervisees if they would change to text

only, and explained why. Was that fair on supervisees? Did their awareness that I was unwell affect their ability to concentrate on what they wanted to bring, or might they have felt the need to take care of me during our session? On the other hand, was it more important for them and their clients that they did at least have supervision?

I don’t have any answers at the moment, but it has caused me to reflect on both where to draw the line in carrying on working, and whether we are always able to make the judgement about ourselves.

My online supervisor was away, and with hindsight it would have been wise to talk to a trusted online peer. I also have thought long and hard about what I would say to my own online supervisees in

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Ethics & Viruses the same position. The Ethical Framework of the British Association for Counselling and Psychotherapy (BACP) for f2f practice states that: “practitioners have a responsibility to monitor and maintain their fitness to practice at a level that enables them to provide an effective service.

If their effectiveness becomes impaired for any reason, including health or personal circumstances, they should seek the advice of their supervisor or experienced colleagues, and if necessary withdraw from practice till their fitness to practice returns”.

That is sound advice, but it may not be that straightforward.

I can think of personal circumstances and health issues that would definitely cause me to stop practicing

at least temporarily, or to recommend to supervisees that they consider doing the same.

However, there is a grey area – a bereavement which from the outside might seem to be of a close relative, but for the practitioner involved is actually not so. The level of physical pain which can be coped with before interfering with the ability to work effectively will vary from person to person.

What has been brought home to me is the need to involve another person in my decision making process, to challenge what might be skewed thinking.

As I write this column, I am aware of feeling quite vulnerable, as I am opening myself up to criticism and judgement from fellow practitioners. However, I

decided that I would still reflect on the dilemma here, as it has brought home to me the difference from f2f work in the decision making process around my ability to work ethically online. I would be interested in hearing about other people’s experiences, both from a supervisor and a supervisee perspective.

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

She can be contacted at anne.stokes4@ btinternet.com.

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Ne wInnovations

How To Start Using Apps in Therapy and Coaching Jay Ostrowski If you have a pulse and a cell phone, you may have noticed the tidal wave of Apps that have come on the market, and many onto your smartphone.

Whether you are tech friendly or not, Apps are here to stay and weaving Apps into therapy and/ or coaching can help you be a more effective counselor/coach and create new opportunities to help your clients.

Using Apps in therapy or coaching just might help your client make a breakthrough.

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How Can an App Be Useful in Therapy and Coaching?

Have you ever had a client that could use a little more self-awareness? Ever wish you could collect more information to understand the extent of the client’s issue or help the client identify patterns? Does your client wonder if the medication is really making a difference? Of course, the answer is “Yes” to all of these. Collecting information is one of the most basic (and easy) uses for Apps. Asking your client to log the “moment,” or collect information at different prescribed intervals

could bring in valuable data into therapy and coaching.

Imagine a client bringing in a completed chart of the targeted emotions or behaviors and corresponding notes for those times.

Remember that worksheet you’ve photocopied until the letters have mostly blurred together? Well, there’s likely an App for that too. Apps can be used to gather information during or in between sessions.

The checklist, journal, log, worksheet, or screening device can all be made (or have already been made) into an App. Since smartphones are carried everywhere, an

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App makes the information gathering much more convenient for the client than a worksheet or a journal, thus increasing compliance and subsequent outcomes.

Examples of Apps for Therapy and Coaching I’ve lost count of the clients that have told me that deep breathing doesn’t work. When I ask them to show me, I’m often entertained by their rendition, which looks much more like hyperventilation. When I don’t have the therapy time to train the client I recommend the App “Breathe2Relax” (free compliments of our US tax dollars). It walks the client through the process with videos, helps them gain self awareness and tracks their progress. Apps like this can serve as an adjunct to therapy or coaching and provide value to the client. Counselors and coaches who become familiar with apps such as this one

can recommend them and save session time for more advanced therapy/coaching encounters.

If you want to track moods, try an App like Moody Me, iMood Journal or Mr Mood (there are many others as well). All three of these programs are free and allow the user to set alarms to rate their mood, a chart of their history and an avenue to write a few notes. Many apps, such as notes, add reminder alerts that come on all smartphones, and can be useful as well. There are many more Apps that prove useful for your clients like ICBT, Habit Pro or Live Happy. For a comprehensive list of over 200 Apps for therapy visit www. telementalhealthcomparisons. com/APPS and consider testing a few on yourself.

Caution A cautionary note on intervention Apps. Make sure that you are comfortable with the developer and material in

the App. The FDA is working on regulations to monitor and regulate Apps that are relied upon for clinical decisionmaking and interventions. Until Apps are regulated, counselors should treat Apps like they would a self-help book and ensure that the materials are sound and appropriate to the client. There are a lot of Apps on the market that are simply entertaining or poorly done.

So take a moment and try out an App and test it before you recommend it.

How to Start There are MANY uses for Apps, but if you are brand new to using Apps in therapy or coaching, start by considering what you already use and see if there is a cross over product.

The best way to start using Apps in therapy or coaching is to find ways to use an App to do what you already recommend to clients. Make sure that the recommendation fits the goals of the client and

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About the Author the client has a clear rational for using it. I tend to frame this as an “experiment” to gather more information for a few days. Clients, unless they are compulsive, usually wane in compliance after a few days anyway, so suggest they collect for a few days and save the information for the next meeting.

Resistance In my experience designing and making apps and programs for therapy, resistance has come more from the lack of comfort with something new and ambiguous, rather than the technology itself. Consider how many of us still fear programming TV recording devices, but drive computerized cars and use social media.

Carving out a little time to go through the app with the client will help you assess the client’s ability and willingness to use the App and forecast and prevent any obstacles as well.

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Final Starting Tips

Jay Ostrowski is a Telemental health and marketing innovator with www.

BehavioralHealthInnovation. com. BHI created www. telementalhealthcomparisons. com to help professionals choose technology. He lives in Charlotte, NC, USA.

Once you are ready to recommend an App, take a moment and walk through using the app in session. This will help the client clearly understand what is expected and help the therapist identify any client’s limitations. Be clear on the expectations for use and the worth of the material gathered. Focus on the material rather than the technology.

Keep the time interval for the App use short. Make sure the client is comfortable with the user agreement for the App. Do not have them email the results or post them on social media sites that are not HIPAA compliant if based in the US. The App will not replace the therapist or coach, as many in the change-agent profession fear. We are not working towards the counselor saying “Take two Apps and

call me next week.” Apps, like assessments, self-help materials and worksheets, serve as enhancements to the therapy or coaching process. Uses of Apps in therapy and coaching are as individual as the sessions themselves. Experiment with some of the Apps and send me some feedback on your experiences. n

Disclosure: Jay Ostrowski receives no compensation, financial or otherwise for any of the Apps mentioned in this article.

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René Quashie

Skype

&HIPAA

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Skype

and similar web-based platforms are increasingly becoming a way for many physicians and other health care practitioners to communicate and interact with patients at a distance.

Many telehealth practitioners in particular use web-based platforms for the delivery of care and communications with patients—especially in certain telehealth subspecialties such as telepsychiatry. The reasons are clear. Skype is essentially free—there is no charge for making calls to other Skype users, although there are fees for making calls to mobile and landline telephones. Skype is also ubiquitous. Skype alone is estimated to have approximately 600 million users worldwide, and its many users rely on Skype to communicate with professional associates, family, and friends.

These figures do not even take into account users of other platforms that are proving popular with consumers and professionals alike. In other words, web-based platforms are easy to use and readily available.

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Nevertheless, the issue of whether to use Skype or similar web-based platforms is a vexing one for many health care providers.1 Notwithstanding the fact that Skype is ubiquitous, its use may be inappropriate for health care providers as communication and treatment via web-based platforms raise a number of significant HIPAA privacy and security issues:

Many platforms are proprietary, meaning that health care providers have no way to determine if and what information is stored.

Users cannot reliably develop and verify an audit trail.

There is no reliable way to verify transmission security.

Users have no way to know when a breach of information occurs.

There is a lack of integrity controls to ensure that electronic protected health information is not altered.

By way of quick background, the Health Insurance Portability and Accountability Act and its resulting regulations pertaining to privacy and security (“HIPAA”) require covered entities, such as health care providers, to protect the confidentiality of protected health information, and guard against unauthorized access, use, and disclosure of such information.2 Among other things, HIPAA rules require (or make addressable): 3 Access controls implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access.

Audit controls implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.

Integrity implement policies and procedures to protect electronic protected health information from improper alteration or destruction.

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Person or entity authentication implement procedures to verify that a person or entity seeking access to electronic protected health information is the one claimed.

Transmission security implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.

Security management implement policies and procedures to prevent, detect, contain, and correct security violations.

Assigned security responsibility identify the security official who is responsible for the development and implementation of the policies and procedures required by this subpart for the entity.

Information access management implement policies and procedures for authorizing access to electronic protected health information.

Security incident procedures implement policies and

procedures to address security incidents, including identifying and responding to suspected or known security incidents; mitigate, to the extent practicable, harmful effects of security incidents that are known to the covered entity; and document security incidents and their outcomes.

Breach notification Report notification of any breaches of unsecured protected health information to affected individuals, the Department of Health and Human Services (HHS), and, in certain circumstances, to the media.

The use of web-based platforms, especially those that are proprietary, makes it difficult for health care entities to meet many of their HIPAA obligations. In other words, telehealth providers may carry a higher risk of potentially violating HIPAA rules when they use web-based platforms such as Skype. In the current regulatory climate, not meeting HIPAA requirements carries greater significance than before given the significant increase in HIPAA enforcement activity.4 Recently, a number of organizations (including Open Technology Institute, Reporters

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Without Borders) signed an open letter to Skype which, among other things, requested that Skype publicly release: • Quantitative data regarding the release of Skype user information to third parties, including the number of requests made by governments, the type of data requested, and the proportion of requests with which it complied.

• Specific details of all user data Skype currently collects.

• Its data retention policies.

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• Skype’s view of what user data third-parties may be able to intercept or retain.

• Skype’s policies related to the disclosure of call metadata in response to subpoenas, and its policies and guidelines for employees when Skype receives and responds to requests for user data from law enforcement and intelligence agencies in the United States and elsewhere.

The letter highlights the security concerns consistently

voiced by many within the privacy and security community. Indeed, late last year, a security flaw was uncovered which allowed Skype accounts to essentially be hijacked—enabling wouldbe hackers to sign up to Skype with email addresses already being used by other Skype users and force password resets for any accounts associated with those emails.

For these reasons, many leading information security organizations generally recommend against the use

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of Skype and similar platforms for communications involving health information. These organizations have concluded that web-based platforms are not secure, and are an inappropriate way by which to communicate with patients— given that health information is often times exchanged in such encounters.

None of the concerns highlighted, however, mean that a telehealth professional should not use Skype to engage with patients—only that they understand the greater liability risks involved.

For telehealth providers who decide to use Skype, there are a number of considerations they should review to better protect themselves from potential HIPAA liability: • Request audit, breach notification, and other information from webbased platform providers.

• Have patients sign a HIPAA authorization and a separate informed consent as part of intake procedures.

• Develop specific procedures and protocols regarding use of web-based platforms (interrupted transmissions, backups, etc.).

• Formally train the workforce on the use of these platforms.

• Exclude the use of these platforms for vulnerable populations (i.e., severely mentally ill, minors, those with protected conditions such as HIV).

• Limit to certain clinical uses (i.e., only intake or follow up).

• Use secure platforms with audit trail, breach notification, other capabilities.

Even if practitioners take these and other steps it may not insulate them from potential HIPAA liability (not to mention state privacy and security laws). Thus, to the extent that a provider can use fully encrypted, non web-based and secure technology, they should do so. These services are usually not free, however. But the fact that Skype is free does not make it appropriate for use by health care practitioners.

ABOUT THE AUTHOR René Quashie is Senior Counsel in the Washington D.C. office of Epstein Becker and Green where he focuses on health care regulatory matters and health care policy. He is also a member of the Legal Resource Team at the Center for Telehealth and eHealth Law.

1

For purposes of this article, the term “Skype” will be used to include Skype and similar free web-based communication platforms relying on proprietary voice over Internet technology. Note that Skype and similar platforms are proprietary services.

2

45 C.F.R. Parts 160 and 164.

3

45 C.F.R. §§ 164.308, 164.312, 164.404-410. “Addressable” means that the entity use reasonable and appropriate measures to meet the standard or it can decide the standard can be met without the implementation of an alternative—but it must document this conclusion.

4

According to the HHS Office of Civil Rights, the agency entrusted with primary HIPAA enforcement, complaints regarding potential HIPAA violations reached all all-time high in 2011, the last year for which data is available. (http://www.hhs.gov/ocr/privacy/hipaa/enforcement/data/complaintsyear.html)

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Marketing Toolbox

Clinton Power

If there's one think that bugs me to no end, it's the myths that abound about Search Engine Optimization (SEO). In my work with therapists and coaches, I'm often hearing bizarre ideas about what people think SEO is and what they need to do to improve it.

SEO refers to the factors on and off your website that contribute to where Google and the other search engines rank you according to similar websites (aka your competition).

Not many people are aware that Google takes over 200 factors into account when it's ranking a website. So there is some incredible complexity involved and no one really knows exactly what their search algorithm contains, though many people dedicate their careers to researching SEO to try and understand some of the most important elements.

What's more, there have recently been a number of updates to the Google algorithm in the last year, namely the Penguin and Panda updates, which have hurt some websites significantly in their rankings.

So let's put some of these myths to bed once and for all.

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MYTH #1

I can get on the first page of Google if I pay someone a large monthly fee.

Many of us have heard this promise from slimy SEO marketing companies that constantly harass and spam small businesses.

One of the ways they target small businesses is to prey on the lack of education or information that the general population has about SEO. And because many of us therapists and coaches don't come from a business background, we can be vulnerable to being sold something that we don’t understand in the hope it will deliver results.

If you hear a company or individual promise they can get you on the first page of Google for many hundreds of dollars a month, what they are talking about is Google Adwords, which are the sponsored listings at the top and down the right side of the search results.

Adwords is very complex to set up effectively and you can potentially lose a lot of money in a short amount of time if you don't know what you're doing. Also, only a small percentage of people actually click on the sponsored links,

3

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Myths & Facts About SEO

so even if you pay to get on the first page with Adwords, you won't get as many click throughs as if you are listed in the main search results, often called the 'organic' listings.

Fact No one can get you to organically appear on the first page of Google, no matter how much you pay per month.

If you want to improve your SEO, you need to do lots of your own study and research to make sure you understand what factors you need to focus on to make your website SEO friendly.

Myth #2

My website designer will do my SEO and I won't have to think about it again.

This is another big myth. Many people think you can just outsource the SEO and once someone else does it, you won't have to worry about it again.

Fact Most website designers understand very little or nothing about what SEO is and what effective SEO is for a website.

Don't blindly trust that your designer is taking care of the SEO. Read and learn from the massive amounts of free information on the web about what you need to attend to onsite and offsite to help the SEO of your website. For a good place to start, check out this website: www.seomoz.org.

MyTh #3

Once my new website is done it will be on the first page of Google.

A therapist said to me the other day "now my website is done, when will it be on the first page of Google?" While this might sound naive, it's actually a common misconception of many therapists and coaches. I always say good SEO is a marathon, not a sprint. It's something that comes from months and years of hard work.

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Fact Once your website is built, the work of improving your SEO begins, not ends.

If you want to stop working on your website once it's built, that's fine, but just know that it won't be appearing anywhere near the first page of Google anytime soon.

Some of that hard work includes:

Google recently released this great website on how search works. Check it out here.

• blogging on a regular basis with interesting and desirable content that people want to consume and share • guest blogging on related websites with your best content that adds value to their readers • being active on other websites through adding engaging comments that contribute to the discussion • building real online and offline relationships with other businesses related to yours • building your community on different social media platforms (especially Google+, because they do own search after all) In short, it's not for the faint of heart. If you think there are shortcuts, know that there aren’t. Google is becoming so smart that any shortcuts people have found in the past are quickly removed and the result is often a significant drop in your rankings for trying to take short cuts.

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ABOUT THE AUTHOR Clinton Power is a Sydney-based Gestalt therapist and the owner of Clinton Power + Associates - a private practice dedicated to helping singles and couples move out of relationship pain. He is also the founder of Australia Counselling Directory, a free directory for find counsellors and psychologists in Australia. Clinton is also a passionate coach and consultant for healthcare professionals. Find him on Google+ or Facebook.

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TILT – Therapeutic Innovations in Light of Technology

“Every book you pick up has its own lesson or lessons, and quite often the bad books have more to teach than the good ones.” ~stephen king

Love For the

Books of

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The book explores social media and mobile as tools, presents guidance on privacy and security challenges, and provides helpful advice on how providers can get started. Vignettes and 23 case studies showcase the impact of patient engagement from a wide variety of settings, from large providers to small practices, and traditional medical clinics to eTherapy practices.

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