Therapeutic Innovations in Light of Technology by Online Therapy Institute

Issue tHREE January 2011

An Ethical Framework for the Use of Social Media by Mental Health Professionals PAGE 20

PAGE 9

Navigating Conflicts by Email PAGE 35

Conferencing in Second Life â&#x20AC;&#x201D;a Newbie's POV! PAGE 38

Time for a Wedding! 10 good reasons for a marriage between Global Mental Health and the New Technologies PLUS...

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

TILT - Therapeutic Innovations in Light of Technology TILT is the magazine of the Online Therapy Institute, a free publication published six times a year online at www.onlinetherapymagazine.com. ISSN 2156-5619 Volume 1, Issue 3, january 2011 TILT Magazine Staff Managing Editors Kate Anthony & DeeAnna Merz Nagel Magazine Production Coordinator Agnes Ikotun Magazine Design and Layout Delaine Ulmer Magazine Advertising Manager Betsy Schuff Associate Editor for Research Stephen Goss Associate Editor for Innovations Mark Goldenson Associate Editor for Supervision Anne Stokes Associate Editor for Marketing and Practice Building Susan Giurleo Associate Editor for Film and Culture Jean-Anne Sutherland Associate Editor for Legalities Jason Zack Advertising Policy The views expressed in TILT do not necessarily reflect those of the Online Therapy Institute, nor does TILT endorse any specific technology, company or device unless Verified by the Online Therapy Institute. If you are interested in advertising in TILT please, review our advertising specs and fees at www.onlinetherapymagazine.com Writer’s Guidelines If you have information or an idea for one of our regular columns, please email editor@onlinetherapymagazine.com with the name of the column in the subject line (e.g. Reel Culture). If you are interested in submitting an article for publication please visit our writer’s guidelines at www.onlinetherapymagazine.com.

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

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Features

9 Navigating Conflicts by Email

20 An Ethical Framework for the Use of Social Media by Mental Health Professionals

35 Conferencing in Second Life â&#x20AC;&#x201D;a newbie's POV!

38 Time for a Wedding! 10 good reasons for a marriage between Global Mental Health and the New Technologies

Issue i n e v er y

News from the CyberStreet

12 Research Review

16 Dilemma: Reader Responses 18 What Would You Do?! 19 Wounded Genius

31 Reel Culture

32 Legal Briefs

46 A Day in the Life

50 CyberSupervision

52 New Innovations 54 Marketing Toolbox

56 Get Verified!

57 OTI Open Office Hours 58 For the Love of Books 61 Advertiserâ&#x20AC;&#x2122;s CyberMarket

A Note From the Managing Editors… Welcome, or welcome back, to TILT – Therapeutic Innovations in Light of Technology – for our 3rd Issue. Our aim continues, issue by issue, to keep you up-to-date with developments in innovations in service delivery; publish interesting articles; provide resources; feature members and friends of the Online Therapy Institute; and include a dose of humour along the way from our resident cartoonist, Wounded Genius. All our regular columnists are here, with useful and entertaining comment on research; online supervision; marketing; film culture; legalities; and new innovations. We also have our member’s responses to our last Ethical Dilemma, and a new one for you to consider and to post responses at our social network forums for publication in Issue Four. We will also be looking forward to Lyle Labardee from LifeOptions.com joining us next issue with a regular column on online coaching. Our featured online therapist member this month is Ralph Friesen, an online counsellor with Shepell•fgi, based in Nelson, BC. We also have two more books to share with you: Wellness & Writing Connections: Writing for Better Physical, Mental, and Spiritual Health, edited by John Frank Evans, shows us how writing is used to heal physical illness, emotional trauma, and spiritual pain. Virtual Worlds (Learning in a Changing World) by Judy O'Connell and Dean Groom challenges us to accept that virtual worlds are here to stay and that schools can, and should, embrace learning in interactive environments. We have four articles for you this month: We introduce the new OTI Ethical Framework for the Use of Social Media for Mental Health Professionals, co-authored with Keely Kolmes, because as more mental health professionals use the Internet to provide telehealth services, promote their practices, or simply to engage with friends and family, there is a need for greater understanding of the potential ethical dilemmas which may arise for those with an online presence. Paul Silverman discusses the importance of navigating conflicts when they arise in email communication, and Deb Owens discusses her experience of attending a conference in Second Life for the first time. Roos Korste claims that it is time for a wedding, giving us 10 good reasons for a marriage between Global Mental Health and the New Technologies. We hope you enjoy our third issue, whatever professional world you inhabit. All feedback is heartily welcomed at the OTI social network!

Managing Editors T I L T MAGAZ I N E j a n u a r y 2 0 1 1

TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

NEWS from the

CyberStreet The Cyberstreet is here to keep you informed of news even if you havenâ&#x20AC;&#x2122;t found time to visit the Online Therapy Institute Website or Social Network!

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

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Blog News… Here is a glimpse of what is going on…get a taster and then head to http://www.onlinetherapyinstituteblog. com/ and the blogs at www.onlinetherapysocialnetwork.com for more! DeeAnna continues to post great resources about the more technical side of being an online mental health professional, blogging about further reasons for using encryption whether you need to be HIPPA compliant or not. She also gives hot tips for using Twitter for Success in business. Kate shares the important work of OTI member Duncan Craig, who is a researcher in the UK and has recently published his valuable work online looking into the use of the Internet and online resources by male adult survivors of childhood sexual abuse. Kate also shares her abstract and evidence submitted for her recent Doctorate in Psychotherapy via Public Works, awarded in December 2010 for her work in developing the field of counselling and Psychotherapy in light of technology and the Internet. You will also find news of the Institute’s new training status as being Endorsed by the British Association for Counselling and Psychotherapy - both for our online 6-module course and our face-to-face one day workshops. BACP Endorsement shows that Online Therapy Institute’s activities are relevant to the professional development of counselling and/or psychotherapy professionals, at a level appropriate for the target group, and are designed and organised in a manner consistent with achieving the stated aims and objectives. Kate and DeeAnna each contributed an article to the newsletter of the Mental Health Informatics Special Interest Group of the Royal College of Psychiatrists, in their special feature Informatics in Psychotherapy, which is full of many great reads. Over at the Social Network blogs, Kylie-Jane Coulter blogs about her experiences with difficult personalities in text-based online counselling; Chaplain Royal Bush continues to share his daily affirmations with us; DeeAnna tells us about the 3D Aids Quilt project in Second Life that was launched in December and which OTI attended; and Eileen Manglass tells us about her attendance at one of the OTI free monthly Open-Office Hour chats in December. T I L T MAGAZ I N E j a n u a r y 2 0 1 1

TILT – Therapeutic Innovations in Light of Technology

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

Member news… Melanie Gorman: YourTango.com launched their latest video on December 1st, a parody on an after school special about social media addiction and relationships: "Social Media Addiction: Are You At risk?" http://www.yourtango.com/201064181/ social-media-addiction-are-you-risk. It's truly funny and a campy look at social media from the perspective of an 80's "after school special". For those of us of that generation, it's a hilarious blast from the past and is sure to get a chuckle or two out of anyone who has dabbled with Twitter, Facebook or ever played one of those superaddictive games like Farmville. Kate Anthony was made Executive Specialist for Online Coaching for the new British Association for Counselling and Psychotherapy Coaching Division, advising the organisation on Best Practice for using technological solutions when working online as a coach.

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Paula Abramson Bloom has been featured on CNN and CNN, HLN and CNN en Espanol discussing various topics ranging from the Chilean Miner Rescue, missing children cases and suicide within the Hispanic community to the DSM V and the controversial removal of the diagnosis of Narcissistic Personality Disorder. We look forward to hearing more about her budding career as she represents the helping profession in the media. Lyle Labardee recently shared this news via a press release: The Center for Credentialing and Education (CCE), an affiliate of the 45,000 member National Board for Certified Counselors (NBCC) approved the Institute for Life Coach Training (ILCT) as the first and currently only qualified provider of coach training for those seeking to become Board Certified. The ILCT is now accepting registrations for the inaugural Board Certified Coach training class beginning in January. Linda Fogg Phillips, co-author of the book, Facebook for Parents, has recently appeared on Fox News. She has also partnered with Online Therapy Institute to create an online course for parents, coaches and therapists about the Facebook culture. Stay tuned!

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Navigating Conflicts by Email Paul Silverman Working as a therapist in modern society, with our scope of practice covering interpersonal relationships, inevitably brings up issues around communications that occur online. With this in mind, I have developed a clinical specialty of working with Internet issues and online relationships – a fascinating course of study, and deeply relevant to so many of our clients. One of the most common dilemmas that clients discuss with me involves interpersonal conflicts that happen over email exchanges. The question always presents itself: Should I respond to this situation in an email? And if so, what’s the best way? For a long time, I would advise people never to hold emotionally charged conversations by email, because the lack of nonverbal or even vocal cues in a typed message remove too much crucial information from the communication. My thinking is a little more nuanced now, and it’s useful to consider both the benefits and the shortcomings of email, especially when you’re trying to work through an interpersonal conflict. If you’re feeling angry, anxious or overly negative about a problem with another person, you should consider some of the unique aspects of email and decide whether this method of communication is right for your situation.

Email communicates words, and words only. This is the most obvious aspect. The recipient of your email won’t be seeing your body language or facial expression and won’t be hearing your vocal tone or volume—these are all enormously influential parts of face-to-face communication. You might think that your words can only be interpreted one way, but you’re not in the other person’s shoes. Try this: say aloud, as if you were talking to someone else: “I can’t believe you decided to do the project that way!” in the most admiring, respectful way you can. Now say exactly the same thing, and give it the most baffled, disgusted tone you can manage. Precisely the same words, with completely opposite

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meanings. The reader of an email wouldn’t get which way you meant. Even emoticons can sometimes be misinterpreted! Email in the midst of a charged conflict often calls for you to write more simply and directly than you might otherwise, to minimize the chances of misinterpretation. Some people like to show their draft emails to others they trust, in order to get impartial feedback on how the words are coming across. Email gives you control over time, place and content. If you’re having a serious fight with someone and feel that being in the same room with him/her would fluster you to the point that you couldn’t fire on all cylinders, email lets you compose your statement in a safe space, without the other person present to trigger you, at your own comfortable rate. It allows you to go over your message as many times as you like until you’re certain that you’re expressing yourself in exactly the way you want. Reading can often be more triggering than hearing. If you’re having an argument with someone and you say something that the other person doesn’t want to hear, he/she might get angry or frustrated at that moment, but the argument is still happening, and you’re right there—this gives the other person incentive to

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stick with it. In an email, it’s easy if you see a word or phrase that sets you off to skip the rest of the message—even if you think you’re still reading it, you might find that your eyes are still moving over the words but you’re really just steaming about the appalling phrase you read in the previous paragraph. People have even been known to hit Delete reflexively when an email wasn’t going the way they wanted. On the other hand, an email gives the reader a chance to stop and “cool off” before continuing—something you don’t often get in the heat of a face-to-face argument.

or near-instant response. This can lead to great bouts of mindreading when the response doesn’t come right away, trying to guess what the other person means by waiting an hour, a day, or a week. Are you comfortable waiting until the other person is ready to respond? Sometimes the response never comes, leaving you wondering even more (keep in mind the possibility of the spam trap!) For that matter, sometimes the other person decides that the argument has to be taken offline and dealt with face-to-face, even if you’ve decided that email is the way to go.

You have no control over the timing of the other person’s response.

Different people have different writing styles.

Because email travels instantly, we sometimes expect an instant

When an important topic is being discussed, some people are brief and to the point, while others write

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lengthy, detailed treatises. If the person you’re corresponding with seems overly short or excessively wordy, don’t assume that this approach means the same thing from him/her as it would if you were writing it. Email lets you make your statement without hearing the immediate reaction. Is this good or bad? Some would say that this can lead to making fiery, confrontational accusations or insults, knowing that you can “go away” after hitting Send and avoid the recipient’s possibly explosive first response. On the other hand, if you have something that you’ve needed to express to someone for a long time and have refrained because you felt that you couldn’t handle the immediate flash of anger or sadness you would get back, email might remove that barrier for you.

wrote, and that you can always refer to the literal content of what you did write?

yourself and see if it comes out sounding the way you mean for it to come across.

Depending on your particular situation and comfort level, email might or might not be the most helpful medium for managing an interpersonal conflict. If you choose to proceed by email, you might find the following routine helpful:

3. After you hit Send, don’t sit at your computer in anticipation of the response. Rather than sit in the anxiety of whatever comes next, make a plan to go and do something enjoyable or fulfilling right away.

1. Don’t compose your email right away, when you’re the most upset. Take a time out away from the computer, tend to a few other tasks in your day, compose the occasional phrase in your head, then later sit down and start writing.

About the author

2. After you’ve written a draft, don’t hit Send right away. Go away from it for a bit, then come back and reread. If possible, read it aloud to

Paul Silverman, MFT Intern, works in a private practice setting in downtown San Francisco, supervised by Adam Zimbardo, MFT. In addition to Internet/online issues, his areas of focus include cognitive-behavioral therapy, bereavement and grief, and harm reduction. His website, www. sfcounseling.net, has a blog about Internet psychology called “Two Tin Cans” at www.sfcounseling.

Email can be forever. What you say in an email is text that your reader now holds for as long as he/she chooses. It is exactly quotable later—by you, by the recipient, or by anyone you or the recipient has chosen to cc. Does this concern you to know that your words today might be brought back to you weeks or months from now? Or is it helpful to know that you won’t at some point in the future have words attributed to you that you never

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TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

Research Review

Online Practitione of Counselling This study, carried out at the University of Wales (Thomas, 2009), explored online therapy practitionersâ&#x20AC;&#x2122; perceptions of the advantages and disadvantages of online counselling using a mixed methods research design. 7 online counselling practitioners provided the qualitative data by means of one-to-one online interviews, and 120 online practitioners completed a 101 item self-report online survey.

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Using online methods of communication allowed access to a global audience and participants were recruited from all five continents. The majority of the survey respondents (40%) resided in the United States of America (USA) and 24%in the United Kingdom and Ireland (UK/Eire). Smaller proportions of respondents were made by residents of Australia (10%), Canada (9%),

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S t e p h e n G o ss f e a t u r i n g H e l e n Th o m a s

ersâ&#x20AC;&#x2122; Perceptions g in Cyberspace Mainland Europe (6%), New Zealand (5%) and Africa (1%). Asia, Israel, India, Mexico, St Lucia, and Turkey were also represented. Remarkably, just under half the sample had no specific training in online therapy provision, suggesting a significant need for take up of the trainings that are already available, as well as education in the field regarding ethical practice which sees such training as highly desirable, at least, and is seen as an ethical pre-requisite by many. It is commonly believed that younger people are more comfortable using the Internet and computer mediated communication yet, interestingly, the largest age group represented in the survey sample was 50-59 with nearly half the sample (49%) being over 50 years of age. Just over two thirds of the respondents were female (68%) and most also worked in face to face settings, online work comprising only a third of the workload of the sample overall. The most commonly used theoretical orientations were the person-centered/experiential or humanistic, CBT and solution focused approaches, with psychodynamic and systemic methods also being notable (other therapeutic schools used less frequently included transactional >

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analysis, behavioural, existential, Adlerian, gestalt and analytic approaches, among others). Email and chat were by far the most commonly used technologies with video, message boards and virtual reality being reported as in use far less frequently. Confidence in online therapy was very high. It was perceived as both more secure and confidential than face to face work and, significantly, as being more effective overall. 53% of respondents who gave an indication preferred online to face to face therapy. A large number of variables were identified by the research. The most frequently reported advantages of online therapy were theInternet’s ability to facilitate the delivery of therapeutic services remotely, and the sense of privacy and anonymity afforded to the client. The reduced power imbalance between therapist and client and the potential for rapid rapport building afforded by the online disinhibition effect were also perceived as significant factors that advantage the therapeutic relationship in an online environment. The most frequently reported disadvantage was reduced ability to intervene in a crisis or emergency situation. 59% indicated that they considered that online counselling is not suitable for clients who present with suicidal ideation and 68% indicated that online counselling is not suitable for clients who report a recent psychotic episode. Online practice has sometimes attracted criticism because

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of the absence of physical presence in an online environment (Alleman, 2002; Bloom, 1998; Childress, 1998; Robson & Robson, 2000). However, while the practitioners in this study perceived that the lack of nonverbal cues presented some disadvantages, such as difficulty in assessing the extent of a client’s distress, the lack of visual information was not perceived as significantly limiting to practice. Contrary to the criticisms in the literature, 70% of participants reported that they were able to compensate for the lack of non-verbal cues when working through a text-only medium. Furthermore, practitioners of online counselling were found to perceive the many advantages of the modality actually outweigh the disadvantages – evidence for this finding from the frequency of qualitative responses being confirmed by triangulation with overall modal scores from the survey. The study also showed that, to an extent, the limitations could be minimised. A further interesting characteristic that emerged from this study was that, in theory at least, there appear to be therapeutic benefits that are unique to online counselling and benefits that are superior to face-toface therapy, such as the degree of intimacy fostered by the online environment. This suggests that further research to directly investigating the therapeutic effectiveness of these unique characteristics would be both interesting and beneficial. n

References

Alleman, J. R. (2002) Online Counseling: The Internet and Mental Health Treatment. Psychotherapy, 39(2), 199-209. Bloom, J.W. (1998) The Ethical Practice of WebCounselling. British Journal of Guidance and Counselling, 26(1), pp. 53-59. Childress CA. (1998) Potential Risks and Benefits of Online Psychotherapeutic Interventions. [html document] available at: http://www.ismho.org/issues/9801.htm [accessed 07/09/08] Robson, D. & Robson, M. (2000) Ethical Issues in Internet Counselling. Counselling Psychology Quarterly, 13(3), 249- 258. Thomas, H. (2009). The Pros and Cons of Counselling in Cyberspace: An Exploratory Study of Online Practitioners' Perceptions. [Unpublished Masters dissertation] University of Wales Newport.

Helen Thomas, MA, MBACP, is a Counsellor and Supervisor based in Cardiff, Wales. UK. She completed this research in partial fulfilment of a Masters degree at the University of Wales Newport 2008-2009. Stephen Goss, Ph.D. is Principal Lecturer at the Metanoia Institute, and also an Independent Consultant in counselling, psychotherapy, research and therapeutic technology based in Scotland, UK.

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

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TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

Reader Responses

Ethical Dilemma IN THE LAST ISSUE WE ASKED:

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

Editor COmments:

Client preference opened up the world of online therapy in the first place. Following her lead at this point carries risks but also provides opportunities for work that might otherwise be unlikely to happen at all.

Establishing a therapeutic relationship online may be the first opportunity the client has in experiencing a positive interaction via the internet.

Reply by Reply by

Kate Anthony

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DeeAnna Merz Nagel

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The stated therapeutic goals have obvious possibly pathological content - eg, perhaps agoraphobia in addition to the risk of re-enforcing the addiction she is seeking help for - though there is far more information needed to diagnose, of course. Consequently, the stated goals are not ones I could agree to outright and would want, at least, to challenge. However, I would take on this client with a view towards dealing with the issues. I would want some pre-therapy discussions to ensure that our goals could be sufficiently shared and would very probably have the idea of transferring to F2F work (perhaps with another therapist) later on as an explicit, if tentative, part of those discussions. The client has a right to choose their lifestyle tempering my intentions to treat their goals as *necessarily* pathological, however much I may want to challenge them, and that would likely form part of our discussion either pre-therapy or early in the process as well. But overall, here is a person seeking help and my role is to provide it to the best of my ability. They will encounter a full, honest relationship with me online and that will be the key to successful treatment - so let's start there and see how much we can do..

Reply by

Stephen Goss

Meet the client where she is at and with the service she is capable of receiving -- go ahead with Internet-based counselingâ&#x20AC;ŚI think a very early discussion -- perhaps right upfront -- would be that I want her to honestly strive to move towards home-based, and then community center counseling as she feels more comfortable. This would be a stated goal of therapy ideally.

I know some may claim it's unethical to accept as an e-client her due to the fear of "doing harm" in reinforcing the internet addiction. I think we would be unethical to turn her away. I would focus on getting more information about why she sees this as an addiction, and the contradiction between wanting help for it, but wanting to ensure that she never has to leave the house. What is it about the addiction that's a problem? It may not be an "addiction", but a social anxiety issue.

Reply by

Larry Saidman

Reply by

Michael Reeder T I L T MAGAZ I N E j a n u a r y 2 0 1 1

TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

Hi Eve ry o n e!

In each issue of TILT we shall be presenting an ethical dilemma about a Web 2.0 experience and other ethical topics related to mental health and technology, and inviting readers to comment at the Online Therapy Instituteâ&#x20AC;&#x2122;s social network. In the following issue of TILT, we shall publish a selection of comments about what YOU would do when faced with the dilemma, as well as our own considerations about what the issues are.

What Would You Do? dilemma You are a therapist hiring a room in a local community centre, which houses a doctors surgery, community facilities such as garden projects and music studios, and an internet cafe. On your last journey through the doors of the centre, you notice that it is now a "check-in point" for the mobile/ cellphone app FourSquare. Your knowledge of this app is that it is a community game, and you read in the national press that it can identify locations alongside the identity of any user. You know your client is an avid gamer and they have mentioned their need to succeed in games. What would you do?! Weigh in here! http://onlinetherapyinstitute.ning.com/forum/ topics/ethical-dilemma-what-would-you-1

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

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BY Keely Kolmes, DeeAnna Merz Nagel and Kate Anthony

An Ethical Framework f the Use of Social Media Mental Health Professio

for a by onals

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Introduction As more mental health professionals use the Internet to provide telehealth services, promote their practices, or simply to engage with friends and family, there is a need for greater understanding of the potential ethical dilemmas which may arise for those with an online presence. I have found the development of a private practice social media policy to be a useful way to mindfully approach online activities without compromising the clinical relationship. Many other psychotherapists are creating their own policies to address how they manage online interactions with clients. DeeAnna Merz Nagel and Kate Anthony asked me to partner with them on creating an Ethical Framework for the Use of Social Media for Mental Health Professionals. Our Framework encompasses the issues of all therapists who are active on Social Media sites窶馬ot simply those clinicians who are providing telemental health services. These are our best practice recommendations.

The Framework A competent practitioner working online will always adhere to at least the following minimum standards and practices in order to be considered to be working in an ethical manner. Practitioners have a sufficient understanding of their Ethics Codes and Social Media and can integrate how they relate to professional conduct online. Practitioners are mindful that Social Media activity can blur the boundaries between personal and professional lives, and they take great care to consider the potential impact of these activities on their professional relationships.

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Applicable Ethical Principles Relevant to Clinical Care and Social Media: • Confidentiality: Practitioners understand that it is their primary obligation to protect client confidentiality and they understand that this means they must also protect confidential information stored in any medium. • Multiple Relationships: Practitioners refrain from entering into any multiple relationships when these relationships could reasonably be expected to impair objectivity, competency, or effectiveness in performing clinical functions or if they pose any risk of exploitation or harm to those with whom we enter into these relationships. • Testimonials: Practitioners do not solicit testimonials from current clients or others who may be vulnerable to undue influence. Since past therapy clients may return to treatment at some point, practitioners who wish to act conservatively in respect to avoiding exploitation of clients will not solicit testimonials from past therapy clients.

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• Informed Consent: When practitioners conduct therapy, counseling, or consultation services in person or via electronic means, they obtain the informed consent of the individual or individuals using their services as early in treatment as is feasible, in language that is easily understood. Informed consent includes information about the nature and course of treatment, fees, involvement of third parties, and limits of confidentiality. Clients must also be given sufficient opportunity to ask questions and receive answers about services. • Minimizing Intrusions on Privacy: Practitioners do not discuss confidential information on listservs or status updates on their social networking profiles. Practitioners discuss confidential material only for appropriate scientific or professional purposes and only with persons who are clearly related to their work (e.g. formal clinical consultation that is documented and that takes place in private settings, not publicly archived settings). Practitioners only include

information in reports and consultations that is relevant to the purpose for which the communication is being made. Details of disclosure in the case of research or consultation should be discussed during the informed consent process. • Initiating Professional Relationships: Practitioners are aware that confidential relationships do not take place in public and they make efforts to minimize any intrusions on privacy including, but not limited to, people contacting them in public forums (e.g. Facebook, Twitter, blog comments, etc.). They make efforts to channel these conversations to a private forum without drawing attention to the fact that they are being contacted for professional services. • Documenting and Maintaining Records: Practitioners create, maintain, and store records related to their professional work in order to facilitate care by them or other treating professionals and to ensure compliance with legal requirements.

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Social Media Interactions Which Relate to Ethical Principles: • Personal vs. Professional Behavior on the web for practitioners: Practitioners are aware of the implications of discussing clinical issues within their social networks in Tweets, status updates, and blog posts, and they are aware that messages may be read by wide networks of nonprofessionals. Practitioners are

aware that even masked data may provide enough detail to potentially identify a client. Practitioners understand that messages posted on personal and professional networks may be archived and seen by other parties to whom they are not authorized to release confidential information, and they adjust their behavior accordingly. Online case consultation that reflects client material, even with the record appropriately blinded, should occur in encrypted

(or equivalent) environments only. • Friend and follow requests: Practitioners are mindful of the ways that connecting with clients on social networks may potentially compromise client confidentiality or may create multiple relationships with people with whom we have already established one type of professional relationship. • Search Engines: Practitioners let

clients

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know whether they utilize search engines as a standard means of collecting client information, whether this is done routinely as part of care, or whether there are particular circumstances (i.e, emergencies) in which they may obtain this information. Practitioners document such activity in clients’charts if this is an aspect of providing clinical care and/or assessment. • Interacting Using Email, SMS, @replies, and other on-site messaging systems: Practitioners are aware that third-party services that offer direct messaging often provide limited security and privacy. Practitioners remain aware that communicating on such systems with clients may expose confidential client data to third parties. Practitioners inform clients at the beginning of treatment about appropriate ways to contact them and let clients know that if they choose to send messages on these networks, these messages may be intercepted by others. Practitioners are aware that all messages exchanged with clients may become a part of the clinical and legal record, even when strictly related

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to housekeeping issues such as change of contact information or scheduling appointments. All therapeutic communication should offer encryption security or the equivalent. Practitioners should define the record according to the laws of their jurisdiction and according to their defined professional scope of practice.

• Location-based services: Practitioners are aware that placing their businesses as check-in points on LBS’s may allow clients with LBS-enabled devices to indicate when they are visiting their offices. Practitioners understand that this may compromise client privacy and they make clients aware of this potential exposure.

• Consumer review sites: Practitioners are aware that their practices may show up on various consumer review sites and that clients may perceive a listing as a request for a review. Practitioners do not ask clients to leave reviews. Practitioners understand that they cannot respond to any reviews in any way confirming whether someone is or was a therapy client.

• Online treatment: If practitioners are providing telemental health services via text-based or video chat, they are aware of additional ethical requirements related to these types of care (Nagel & Anthony, 2009). Practitioners work within their Scope of Practice. Scope of Practice indicates the specific area to which a practi-

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tioner may practice. Scope of practice in many geographic areas also defines where a practitioner may practice; whether the practitioner may practice across various geographical boundaries and within what parameters a practitioner may practice. Practitioners also follow local and regional laws and codes of ethics as applicable. • Understanding of boundaries and limitations of one’s specific discipline: Practitioners understand which assessments and interventions are allowed within their specific discipline. For instance, career counselors who have no training in mental health issues generally do not provide psychotherapy services. • Understanding of specific laws or ethics within one’s own discipline or geographic location: Practitioners understand the limits set forth by laws or ethics within the applicable geographic location. For instance, in the United States, Licensed Professional Counselors cannot call themselves Psychologists, and in the UK the term ‘Chartered Psychologist’ is reserved by law for use only by those

with proper recognition from the appropriate authorities. Certain states dictate what a practitioner can be called due to the implementation of Title laws. Practice laws may prevent a licensed practitioner from interpreting certain personality tests in one state, yet the same practice may be accepted under Practice law in another state. • Respect for the specific laws of a potential client’s geographic location: Practitioners understand that different geographic regions may offer additional limits to practice, particularly with regard to jurisdiction. For instance, a counselor in the UK should be cognizant of the licensing and practice laws of other jurisdictions. For example, in the state of California the law prohibits practitioners from engaging in counseling services with clients who reside out of state. • Competence: Practitioners understand that knowledge and facility in social media does not exempt one from obtaining training and supervision in specialized care, such as providing telemental health services.

Practitioners work within their boundaries of competence: they seek out training, knowledge and supervision. Practitioners also consult with other professionals, when appropriate. Training, knowledge and supervision regarding mental health and technology is paramount to delivering a standard of care that is considered “best practice” within one’s geographic region and within a global context. Practitioners are encouraged to demonstrate proficiency and competency through formal specialist training for online work, books, peer-reviewed literature and popular media. Clinical and/or peer supervision and support are mandated for practitioners who cannot practice independently within a geographic region and is highly recommended for all practitioners. • Formal Training: Practitioners seek out sufficient formal training whenever possible through college, university or private settings. Formal training is displayed on the practitioner’s website. • Informal Training:

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Practitioners seek out continuing education and professional development and conferences, conventions and workshops. • Books: Practitioners read books written by the general public and professionals. • Peer-reviewed Literature: Practitioners read peerreviewed literature that includes the latest theories and research. • Popular Media: Practitioners are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of mental health and technology on the popular culture. • Clinical Consultation: Practitioners seek professional consultation whenever the practitioner cannot practice independently within his or her geographic location or when practicing outside of their area of expertise. Clinical and/or peer supervision is sought by all practitioners who deliver services via technology. Clinical and peer

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supervision is delivered either face-to-face or via encrypted methods. Practitioners display pertinent and necessary information on Websites and Social Media profiles that are related to their professional practice. Websites that provide information for the general public, potential clients, current clients and other professionals will include the following information. • Crisis Intervention Information: People may surf the Internet seeking immediate help. Practitioners display crisis intervention information on the home page. Practitioners understand that people in crisis may visit the website from anywhere in the world. Offering global resources such as Befriender’s International or The Samaritans is the best course of action. • Practitioner Contact Information: Practitioners offer contact information that includes email, mailing address and a telephone or VOIP number. While it is not recommended that post addresses reflect the practitioner’s home

location, clients should have a post address for formal correspondence related to redress, subpoenas or other mailings requiring a signature of receipt. Practitioners state the amount of time an individual may wait for a reply to email or voice mail. Best practice indicates a maximum of two business days for therapeutic inquiries. • Practitioner Education, License and/or Certification Information: Practitioners list degrees, licenses and/or certifications as well as corresponding numbers. If the license, certification board, or professional body offers a website that allows the general public to verify information on a particular practitioner the license and certification listings should link directly to those verifying body websites. Practitioners consider listing other formal education such as college or university courses, online continuing education and professional development courses, and conference/ convention attendance directly related to mental health and technology.

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• Terms of Use, Privacy Policy, and Social Media Policy: Terms of Use, often all or in part, synonymous with a practitioner’s informed consent, is available on the website either as a page on the website or a downloadable document. The practitioner’s privacy policy is also available in the same way and offers information about if or how email addresses, credit card information and client records are used, shared or stored. Practitioners must ensure that they comply with the requirements of the Data Protection Act and other aspects of applicable law, and in the United States, practitioners display the Notice of Privacy Practices

to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that is required for patient consent in the geographic location of the practitioner should be posted on the website as well. Practitioners who maintain professional accounts on Social Media sites include information about their professional use of these services at the beginning of treatment (Kolmes, 2010). • Encrypted Transmission of Therapeutic and Payment Information: Practitioners offer secure and encrypted means of therapeutic communication and payment transactions.

Email and Chat programs whether embedded within the practitioner site (private practice or e-clinic) or utilizing 3rd party platforms such Hushmail are explained on the website. Payment methods are explained as well through merchant information or information provided by the practitioner. Practitioners offer an Informed Consent process. The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information is accessible via the practitioner’s website. The informed consent process includes a formal acknowledgement from the client to the practitioner. This acknowledgement is received via encrypted channels. Informed Consent content is revisited during the course of therapy as necessary and beneficial. The following topics are addressed within Informed Consent: • The nature and course of treatment. • Treatment fees. • Involvement of third parties and limits of confidentiality.

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• Setting expectations for how practitioner will interact with clients on Social Networking sites. • Helping clients to understand legal risks and implications of online contact (documentation, confidentiality, etc.) • Helping clients to understand the unique nature of therapy relationship. • Clients must also be given time to ask questions and receive answers about services. Confidentiality and Technology • Encryption: An explanation about the use of encryption for therapeutic exchanges and lack of encryption if/when unencrypted methods (standard email, forum posts, mobile telephone, SMS texting, social networking) are used for issues such as appointment changes and cancellations. • Privacy Policy: The practitioner’s privacy policy is also included in the Informed Consent process including information about how email addresses, credit card information and client records are used, shared or stored. In the United States,

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practitioners must include the Notice of Privacy Practices to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that is required for patient consent in the geographic location of the practitioner is included in the Informed Consent process. Other Relevant Issues • Cultural Factors that May Impact Treatment: Practitioners with both personal and professional profiles on social networking sites are aware that cultural factors may influence the likelihood of discovering shared friend networks on such sites. They are aware that shared membership in cultural groups based upon ethnicity, sexual orientation, disability, religion, drug or alcohol recovery communities, and other identifiers may increase the likelihood of discovering overlapping contacts on websites or shared email lists. Practitioners who treat other mental health professionals may also share professional space on various professional social networks or listservs. • Dual Relationships: Practitioners discuss with clients the expected

boundaries and expectations about forming relationships online. Practitioners inform clients that any requests for “friendship,” business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored and addressed subsequently in treatment, to preserve the integrity of the therapeutic relationship and protect confidentiality . If the client has not been formally informed of these boundaries prior to the practitioner receiving the request, the practitioner will ignore the request via the social media site and explain why in subsequent interaction with the client. See above sections of this framework for more detailed information. • Peer Support and Self-Help: When mental health professionals sponsor, host, partner, moderate or facilitate peer support and self-help efforts, such efforts are maintained in a secure and encrypted environment. Conclusion Having a Social Media presence is a great way to enhance one’s personal and professional life. For many

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practitioners, it has become an important part of their professional services. We can only assume that as younger clinicians enter the field, it will become commonplace for more psychotherapists to practice, network, and maintain a presence on Social Media. We hope our Framework has provided a useful model for integrating Ethical Care with modern technology and we are pleased to be a part of the conversation about the conscious application of both. We are also eager to see what the future brings. n

ABOUT THE AUTHORS Keely Kolmes is a San Francisco psychologist who provides psychotherapy services for individuals and relationship partners. She also provides education and consultation to therapists regarding working with sexually diverse clients and managing clinical and ethical issues related to the Internet and clinical practice. DeeAnna Merz Nagel and Kate Anthony are co-founders of the Online Therapy Institute and Managing Editors of TILT Magazine – Therapeutic Innovations in Light of Technology. Keely's website: http://drkkolmes.com

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REFERENCES

American Association for Marriage and Family Therapy. (2001, July 1). AAMFT Code of Ethics. Retrieved from http://www.aamft.org/resources/lrm_plan/ethics/ethicscode2001.asp American Counseling Association. (2005). ACA Code of Ethics. Alexandria, VA: Author. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060 – 1073. Anthony, K. & Goss, S. (2009). Guidelines for Online Counselling and Psychotherapy 3rd Edition including Guidelines for Online Supervision. BACP Publishing, Rugby Anthony, K. & Nagel, D.M. (2009). Online therapy: A practical guide. Sage Publishing: London. Kolmes, K. (2010, February 1). Private Practice Social Media Policy. (Retrieved October 26 2010) from http:// www.drkkolmes.com/docs/socmed.pdf National Association of Social Workers. (2008). Code of Ethics of the National Association of Social Workers. Retrieved from http://www.naswdc.org/pubs/code/code.asp.

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REEL CULTURE

Jean-Anne Sutherland

Santa: The “Fixed Illusion” in Miracle on 34th Street At the time of this writing, we are amidst the holiday season, which also means the inundation of many holiday films. Of course, I am being generous when I say “holiday.” Personally, I have not discovered a plethora of Hanukkah or Kwanza films. And, as I live in the United States, what I really mean is: Hollywood, blockbuster, American, Christmas films. Most folk feel particularly attached to their favorite holiday film. There are the sentimental (It’s a Wonderful Life), the hilarious (Jim Carrey in How the Grinch Stole Christmas) and, the spectacular (The Polar Express). What these holiday films share is the very question that revolves around Christmas: do you, or do you not believe? Do you believe that Christmas, Santa, or any of this is actually real? Ah, Santa, and believing, and “reality.” That’s what Miracle on 34th Street tackles. While it is not the only film to portray belief in the eyes of children – the belief that then slips gloomily from the lives of adults--it is perhaps the best at depicting what social psychologists call perception of reality. This film does not merely ask, “Is Santa real?” It asks the question, “what does ‘real’ mean?” Miracle does not resolve the cultural incongruities of belief, reality, Christmas, and Santa, as do so many other films: Santa flying overhead, empirically demonstrating his real-ness (e.g., Elf; The Santa Clause). That is, once we SEE him, then, and only then are we convinced that he is “real.” Miracle plays with the question of reality itself – and who gets to define it. Naturally, a couple of psychologists are brought in. The uptight empiricist argues that because Kringle insists he is Santa, he is a loony. The second psychologist finds Kringle harmless,

claiming that there are “plenty of people walking around with delusions.” Thus, one’s belief in what is “real,” such as in this case, is ultimately harmless. The prosecutor must prove that Kringle’s beliefs make him a menace to society. Kringle’s lawyer has to convince the Judge that Kringle is the “real” Santa Claus. And the Judge has to rule whether this Santa is “real” or not. During Kringle’s trial, his lawyer asks the Judge if he believes himself to be who he is… Of course, is the answer. The lawyer responds, “If he (Kringle) is the person he believes himself to be then he is just as sane as you are.” Who truly judges what reality is to another? Social psychologists contend that reality itself is a social construction. What is “real” to an individual or group may indeed appear crazy to another. To the symbolic interactionist, truth and reality are produced in social contexts. Miracle asks us to look at our cultural rules about what is “real” and what is not. Moreover, it depicts the western basis of reality (i.e., empirical proof ) and illustrates the social costs of behavior that is, well, not “normal.” Miracle reminds us that the holiday season is about believing without the need for proof. We are asked to let go of our passion for fastidious pragmatism and allow our sense of “reality” to be stretched a bit. Is Santa real? He is to some children. And that, to them, sure feels real. 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. T I L T MAGAZ I N E j a n u a r y 2 0 1 1

TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

Jason S. Z ack

Try This at Home!

Let's take New York, for example. Googling "New York State Board of Psychology" took me right to the state's Psychology page: http://www.op.nysed.gov/prof/psych/ The first link on the left hand side, "Laws Rules & Regulations," took me right to what I needed: Laws, Rules & Regulations Education Law

Title VIII - links to all Articles

Article 153 - Psychology Rules of the Board of Regents Part 29 - Unprofessional Conduct Commissioner's Regulations In discussing legal issues related to online counseling, I inevitably suggest that counselors who decide to work with clients located outside the counselor's jurisdiction should make themselves familiar with the mental health counseling laws and regulations of the jurisdiction where their client is located. My sense is that most counselors probably ignore this suggestion, because they don't know where to start, short of hiring a lawyer. Although that would certainly be the ideal course of action, there is much that online counselors can do to inform themselves for no cost at all. In this month's column, my goal is to walk through that process for a hypothetical professional working with a client in a given state and show you that it's not so difficult to quickly review the basic mental health laws and regulations of a jurisdiction. Your first step should be to check the website of the agency responsible for regulating your profession in that state, e.g., a psychologist should check the state board of psychology, a social worker the social work board, etc. The agency will usually have a page with links to the relevant laws and regulations for that state. They may also have ethical guidelines and statements.

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Part 52.10 - Registration of Curricula Part 72 - Psychology If I follow the link to Title VIII of NY's Education Law - The Professions, I can take a look at the general provisions (Article 130) that apply to all licensed professionals in NY. This is typically where I would find procedures and penalties pertaining to violations of this portion of the code. You'll see, for example, that unlicensed practice is a Class E felony (# 6512) and also can result in civil penalties. This title goes on to discuss enforcement procedures. After reviewing the general provisions applicable to all licensed professions in NY, I can turn to the section specifically applicable to psychologists--Article 153. Article 153 (which begins by confirming that the general provisions in Article 130 apply) defines the practice of psychology, establishes the state board, sets forth licensure requirements, allows for limited

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In addition to the statutes in Article 153, which set forth the requirements for licensure, the Board of Regents Rules Part 29 contains the relative rules pertaining to unprofessional conduct. From the Table of Contents there, it looks like we should focus on the General Provisions in # 29.1 and the special provisions for psychology in # 29.12. Reference to # 29.12 tells me that # 29.2 applies to psychologists too. Reading these three sections tells me what New York expects from psychologists with regard to keeping records, abandoning clients in need, etc. Even if your home jurisdiction doesn't require meeting the same standards of care as New York, it makes sense to follow the highest level of care required by either your home state or your client's state. Incidentally, the navigation bar on the left has a link to the Board of Regents Rules generally. That page contains links to the relevant disciplinary procedures. Part 31 sets out "Proceedings Relating to the Unauthorized Practice of the Professions or the Unauthorized Use of a Professional Title." You'll notice these are similar to those in the general section of the statutes, but also include more specific details like contact information for complaints. That's because regulations are a lot easier to modify and update than statutes, which must go through the legislative process. As for the Commissioner of Education's regulations, Part 52.10 applies to educational programs, not to practitioners. Part 72 discusses licensure requirements.

LEGAL BRIEFS

permits and discusses exemptions. I see that nothing specifically mentions online counseling, telehealth or Internet-mediated service delivery. That doesn't mean the laws don't apply (and it has always been my position that they probably do apply, based on the practice, regardless of the medium), but it does tell me there is nothing specific to note beyond what is generally required of all psychologists in New York.

Finally, you may wish to run some broad searches in the state's statutes and pending legislation to see if there's anything else you might want to know. In New York, this can be easily done at the state legislature's website, here: http://public.leginfo.state.ny.us/menuf. cgi For example, doing a word search for "telemedicine" in the Laws of New York turns up nothing, but a search for that word in the 2010 NYS Legislative Bills reveals that there are two bills using that term as of this writing. One would establish a telemedicine/ telehealth task force and another would provide for a telemedicine study by the commissioners of health and education. Unfortunately, clicking on the bills for more detail suggests that both bills were abandoned in January 2010. This basic process is likely to work in most states. If the state board hasn't done the favor of compiling the relevant laws & regulations, it's usually easy to locate where they are in the state's laws. Just go to the state legislature's website and you should be able to find a link to laws, code, or statutes. Drill down in the table of contents to the title (book, subdivision) that would address regulation of professions or public health. You might also be able to run a text search for the name of your profession. Be sure not to stop at the laws, though. As mentioned above, agency regulations are usually the place where the detailed rules will be

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set out. Finally, check the state board's website for practice guidelines to see if the board has issued any statements related to providing online mental health services. It's amazing how much legal information is available to everyone online for free. That's great because Practitioners are expected to know these things, and the public should be able to know their rights and the basic guidelines their professionals must follow. Although the process discussed here won't give you all of the law that could possibly pertain to online counseling (for example it doesn't cover case law, or judicial interpretations of the statutes at issue), it would get you the basics and should alert you to any big red flags. In a world where it is still an open question as to where online counselors "practice" for licensure purposes, it is likely that any civil or criminal claims against online mental health professionals would cite the statutes of the professional's home state or those of the client. As such you should do what you can to familiarize yourself with both. And apart from a risk-management perspective, a working knowledge of the mental health laws of your clients' states will allow you to more comfortably assure them that they are receiving the standard of care they could expect from an offline mental health professional.

Jason S. Zack is a practicing attorney in New York, New York. He is a former behavioral science consultant and Past-President of the International Society for Mental Health Online (ISMHO). Disclaimer: Any opinions expressed herein are Jasonâ&#x20AC;&#x2122;s own and not necessarily those of his employer. This article does not constitute legal advice and does not create an attorney-client relationship between the author and anyone reading it.

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Conferencing in Second Life —a newbie's

POV!

BY Deb Owens

I’m in my office pondering how to get more of those pesky continuing education credits that all licensed and certified counselors must obtain within their credentialing cycle. An intriguing announcement on a professional message board catches my eye. It details a free 3 day Virtual Conference on Counseling (2VCC) taking place in Second Life sponsored by Counselor Education in Second Life (CESL). Now as a Mom of Millenials and avid reader I’ve heard of SL. I also counsel a few digital natives who believe it’s a good way to unwind. We talked about the potential down side since it can be addicting. There are certainly areas of SL, like the Internet, that should be avoided if you are trying to use your time wisely in healthy pursuits. With one client we work on boosting real life resources, supports, and recreation to off- set the pull of SL, Farmville and World of Warcraft (WOW). As I drop into the live video stream of the conference, which is explained as a way to experience it without being in SL, I observe a workshop occurring in real time. NBCC is offering free CE credits

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only if you attend within the SL construct, providing an incentive to check it out. My interest piqued, I enroll in SL so I can attend the conference “in world’ as they say. Registering is easy but I have no time to check the orientation tools. It’s already late in the evening, so for the life of me, I can’t figure out how to get to the virtual conference, even though one of the organizers says she sent me a LM (land mark): http://slurl.com/secondlife/Port%20 Dervon/81/97/27). Seeing my distress, this kind soul “teleports” me there and low and behold, it’s set up exactly like a real conference, complete with banners, a power point screen, stage and refreshments. On my own, I figure out how to walk into the session and take a seat. After noting my Avatar’s red leather jacket and spike heels I attempt to alter my attire to appear more professional.

teachers establishing worlds where students can participate in pioneer life. Where this all fits for psychotherapy is beyond my expertise but DeeAnna Merz Nagel, who heads up The Online Therapy Institute, is a wealth of information on this subject matter. She maintains a traditional F2F (face to face) practice while also working with clients via the Internet. She has an office in SL and it’s worth checking her web page: http://www.onlinetherapyinstitute.com. I get all the concerns about ethics and confidentiality but rest assured that the folks that are at the cutting edge of this are on top of these things and aggressively addressing them through traditional organizations and boards to ensure best practices.

Suddenly, I find myself bald. I give up on the hair endeavor and instead choose to listen and watch the presentation. It’s similar to lots of live webinars I attend through various professional associations although, in addition to sound and slides, I feel part of a unique learning community. A chat is occurring amongst attendees as the session unfolds. It’s well done and the few technological glitches are addressed as much by the attendees making suggestions as by the organizers. Despite my promise to never use this word, I have to admit, the whole experience is “epic”. Why? It’s compelling to hear some of the ways other professions are using this technology, including 36

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Exiting the conference I can’t resist a brief detour to visit two of the myriad of incredibly vivid worlds in Second Life. I stumble upon a deep sea setting and a fire pit chat. The latter encounter turns ugly when a few teens, allegedly from the UK and Japan, start using slurs. Returning to the Real World I’m grateful for this chance to see what all the fuss is about. I’ve glimpsed what the next generation of potential clients may experience. Will I go back? It’s doubtful that I’ll do so for social purposes. However, as a counselor training process I’ve discovered an excellent way to obtain professional education. I recommend it to my peers as another option to consider and look forward to seeing how it develops.

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The next evening I find my way back to the conference site to grab the articles that were mentioned by a presenter. There’s a kiosk. It looks like I just need to identify which clicks to use to accomplish the task. Another Avatar comes along, asks if I know how to locate the materials. He has the impression that they might be available in another room but leaves before I can request that he teleport me there. While I wait, hoping he’ll return, I send a thank you email to the avatar associated with the sponsoring organization www.onlinevents.co.uk that guided me here. Perhaps she’s been keeping an eye on my newbie antics since she IM responds and, oh so kindly, offers to assist me in getting back my hair.

Now it’s been a couple of months since the conference and in case you are wondering, no I haven’t engaged again with Second Life. I popped in once about a week later and checked out a few things but my level of interest was not high enough to take the time to use the tutorial and get up to speed on how to make the system work for my needs. I would absolutely attend SL training events again and can see how therapy within a legitimate SL arrangement, with a licensed professional who was following all the appropriate ethical guidelines, can be beneficial for some clients. I look forward to seeing how this technology evolves and expect to see both challenges and amazing opportunities emerge. n

ABOUT THE AUTHOR In addition to providing individual and couples counseling in her private practice in Montgomery and Philadelphia Counties in PA, Deb Owens offers training and consultation for the behavioral health field. She is also an onsite EAP at a Fortune 100 company and has been a Director or Manager with several high quality Employee Assistance, mental health, and addictions programs and conducts training and team building for corporations and treatment providers. http://www.debowens.com

Photographs courtesy of Saz Wilson, OnlinEvents Events Coordinator T I L T MAGAZ I N E j a n u a r y 2 0 1 1

Time

10 good reasons for a marriage between Global Mental Health and the New Technologies

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for a Wedding! BY Roos Korste

As one can read in the 2007 Lancet Series on Global Mental Health, it is estimated that mental disorders contribute to 12% of the global burden of disease and make up 5 of the 10 leading causes of health disability. In the meantime, 75-85% of people with mental or psychosocial disabilities have no access to any form of formal mental health treatment in developing countries, the so called “mental health treatment gap” or mhGAP. In order to join forces and turn the international and national policies, a couple of initiatives have been launched since 2005, like the Global Movement of Mental Health and this mhGAP program. International Mental Health conferences, like the one in September 2009 in Athens and the next in October 2011 in South Africa, and WHO reports like Mental Health and Development and other big, small, local, regional actions, courses and research are all an effort to scale up the mental health services. Although, this all sounds great and positive, for me it still smells too much like the old paperwork, academic corridors, agenda’s-meetings-thick reports and hierarchies. Not wrong, but we are gifted with the 21st century new technologies! In this era, ‘everyone’ can be online and on the phone; everyone is equal and accessible; everyone can search and connect; and everyone can contribute to plans and innovative thinking. Thus global mental health must not only engage with the new technologies; for a real demand driven, affordable

Most people with mental disorders in low income countries receive no treatment at all for their mental illnesses. The new technologies, like the Internet and mobile devices, can solve part of this so called treatment gap. In '10 good reasons' the benefits of ICT in this global health field are clarified. and sustainable care, we must marry the new technologies, embrace and stay together for ever. The scope of this paper is mainly the less served people and the poorest areas of the world. But what has been published and shared about the new technologies and mental health until now is mostly in and from the higher income countries. Examples are the recent published book The Use of Technology in Mental Health and the inspiring International e-Mental-Health Summit in 2009, and the next in April 2011, and online networks like the International Society for Mental Health Online (ISMHO) and the Online Therapy Institute. Up to date and high qualitative information, but not suitable for the chained man with a psychosis in rural Ethiopia, the mentally disabled child with daily seizures due to untreated epilepsy, high in the mountains of Papua New Guinea or the T I L T MAGAZ I N E j a n u a r y 2 0 1 1

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agressive woman in her manic episode in a remote village in Guatemala. I got all the information from the web (of course) and because of the limited publications (yet) on mental health in this regard, now and then I relied heavily on developments and publications of the more general eHealth and mHealth fields.

The new technologies are already there and a worldwide booming business

Although the new technology penetration in developing countries is the lowest worldwide, it’s catching up rapidly with the rest. According to the International Telecommunication Union (ITU), 21% of the population in developing countries are online and 68% have access to a mobile phone network. The ICT prices are falling, but high speed Internet access remains very expensive in the low income countries, and is even nearly 7 times more expensive then in the developed countries. The mobile wireless services are much more available and affordable.

Because mental health users, practitioners, caregivers and family members are online and are using there mobile devices abundantly, we must incorporate these technologies in our global mental health organizations and policies. Otherwise we will miss the connection with the daily reality of this new era.

Affordable mental health care; saving costs

One of the major problems in the mental health care in low and middle income countries is the lack of funding (Lancet Series 2007). In this context i.com, the innovative centre of mental health and technology, states that 'It would be a formidable step ahead when for instance evidence based treatments for mental health disorders could be offered on a broad scale and at low costs over the Internet’. Examples of such Internet based programs are: the international Stop Smoking Site, the UK Beating the Blues program and the Arabic Internet-based treatment of PTSD. Another cost-saving example is tele-nursing, where the client can consult a nurse via the phone for information, advice, a referral or a drug subscription. And last but not least: how much money would we save if we stop travelling around the world for conferences, research, study, consultancies, etc. Count in the primary costs for hotels, meeting venues, the drinks and dinners, and the secondary costs in the loss of time. I know it’s marvelous to travel and

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meet and greet face-to-face, but anno 2010 it sometimes seems already an unnecessary waste of money and anno 2020, I think, it will be a shame.

Reaching people in need in the remote and underserved area’s of the world

Low income countries have a median of 0-05 psychiatrists and 0-16 psychiatric nurses per 100,000 population. In high income countries this ratio is 200 times higher. In countries like Chad, Eritrea and Liberia for instance, there is only one psychiatrist for the whole country. Since most mental health care professionals live in and around the larger cities, rural populations are extra underserved. A mental health care integrated into the primary health care, is the current policy for these countries and area’s. But in these community based models the local lay community workers or low educated health workers need extra training, knowledge, supervision and continuous support from elsewhere. The mHealth and Development report of the UN Foundation and the Vodafone Foundation, the eHealth Tools & Services report of the WHO, and the Question 14-2/2 study of the ITU, all offer a broad array of applications for this remote control support. For instance shared electronic records, computer assisted prescription of medicines and step by step diagnosis decision trees, wiki’s, video conferencing, tele-pharmacy, second opinion and distant consultations. And in order to reach patients in remote area’s, or immobile patients, mental health practitioners can use mobile or Internet care-at-home programs like video monitoring, online encrypted chats/ mail via free providers like Skype and Hushmail, and tele-nursing.

Anticipating on the globalization and movement of people

Immigration is a key part of globalization. According to the ITU in 2007 there were 36 million expatriates worldwide and more then 898 million people crossed national boundaries, which is expected to increase to 1.56 billion in 2020. Emergencies and violence produce large flows of asylum seekers and refugees, often in low and middle income neighboring countries which have little capacity to receive them and take care of them, even more overstretching local limited resources. According to the World Development Report 2011, there were 42.3 million people displaced globally in 2009. Of these, 15.2 million were refugees outside their country. With many countries having multiple local and regional languages, communicating with care givers in the language you know can be crucial for help and accurate advice. Personal health info and records can be accessed online (see point 6) and shared with a professional elsewhere. Free encrypted mail and chat sites (see point 3) make communication with far away mental health professionals possible and with 100% privacy (if used properly), and some of the online interventions mentioned above (point 2) can be accessed worldwide. So, with the new technologies people can 'take their mental health care with them', wherever they are.

Fighting stigma and raise awareness about mental health conditions

A lot of people with mental health problems are subject to stigma, exclusion and discrimination. As Jagannath Lamichhane, a journalist in Nepal,

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explains in Time to Heal, people can have the notion that a mental illness is a loss of face for the family, a result of bad karma, or the individual’s fate and result of bad deeds in past lives. This stigma

have a high Internet presence and/or use the Internet for contact, actions and news.

treatment, and efforts of family members to ignore or conceal the mental health problems of their family member. Often patients are still locked up or chained out of sight and the conditions in many mental hospitals are appalling and treatments abusive. Good examples of mental health stigma fighters with a extensive social media appearance are Time to Change in the UK, Mind Freedom in the US and Sane in Australia.

According to the 2007 Lancet series, training facilities are generally inadequate and on top of that there is a large scale migration of mental health professionals to higher income countries, the so called brain-drain. On top of that, in the community based mental health care models, the specialists will have more roles then merely treating patients and they need additional skills. There are already short courses addressing this leadership in mental health and universities have been launching academic courses in public health, mental health, research and human rights. A few of them are for most part based on elearning.

and lack of knowledge about mental disorders can result in a strong avoidance in seeking

Empowerment and independence of users and caregivers

People with mental health problems, including their caretakers, will benefit from more information about conditions and treatment, more ownership, more possible choices, decisions and support. Nowadays there is 24/7 access to online information, suicide-prevention and emergency sites/telephone numbers like Befrienders Worldwide. There are apps on mobile devices like the T2 MoodTracker application of the US army, Mobile Therapy, a cell phone application for 'emotional self-awareness'. And there are Internet services like Personal Health Records (PHR’s) such as Google Health. With these applications people can manage a part of their mental health care themselves, wherever they are or at what time of the day. Examples of user and self-help groups are Alcohol Anonymous, the World Network of Users and Survivors of Psychiatry and online communities like Intervoice. A lot of these group

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Capacity building in the mental health care

So, development of more, cheap and easy applicable distant- and elearning programs seem a ultimate solution here. Practitioners and students from low and middle income countries don’t need to leave their country or area for years, which is very expensive and bears the risk of not coming back. They can practice on the spot and even in the remote underserved rural places, in their own pace and time.

Global knowledge: together we know more

International conferences, including the travelling and accommodations, are not affordable for most practitioners in low and middle income countries. The same with paper text books and journals. The new technologies can tackle most of this money related obstacles and give ample possibilities

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tuning of relief efforts, including psycho-social support and crisis psychiatry. The Mental Health and Psycho-Social Support Network for example opened a special Haiti 2010 Earthquake Response Group on their online community, with more then 100 uploaded files and 79 members.

Bottom up and demand driven programs

Before the web2.0 era, the information stream was mostly one way, top down, from institutes and plan makers in developed countries, to their recipients in developing countries. In recent reports of the WHO and in the 2007 Lancet series you can see more grass root contributors and now and then reluctant recommendations to consult users and their movements. Indeed the web2.0 offers great opportunities here.

to a two-way information stream. In the mental health field there is for instance the initiative of the Movement for Global Mental Health with packages and programs of care and other upload documents, and the site of the Mental Health First Aid. Other web2.0 applications are blogs, micro blogging like Twitter, video sharing like You Tube, slide sharing, social networks like Facebook, wikiâ&#x20AC;&#x2122;s like the MentalHealthWiki, and free accessible journals like this one - Therapeutic Innovations in Light of Technology, and for example the Journal of the World Psychiatric Association (WPA) and the International Journal of Mental Health Systems. In emergency situations the new technologies can play a crucial role in the coordination and

In the field of the global mental health there are a couple of communities online like the Mental Health Community, the Society for Emotional Well-being Worldwide, and numerous blogs, pages and accounts. A lot of them are individual initiatives and opinions. A nice bottom up mental health activism example is the online petition 'Mental Health is a Global Urgent Issue'. My blog, my in2mentalhealth Facebook page and in2mh Twitter account, are other small web2.0 examples; just a person somewhere in the world, circulating information for whoever wants to read it.......

Useful data for research, planning and evaluation: standardizing and easy access

In the UN Foundation and Vodafone Foundation report about mHealth and Development is stated that 'policymakers and health providers

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at a national, district and community level need accurate data in order to gauge the effectiveness of existing policies and programs and to shape new ones'. But when for instance the World Psychiatric Organization (WPA) reviewed systematically the development of community mental health care in Africa, they find a diversity of data and methods, which gave some insight in the matter, but not reliable figures or clear comparable outcomes. An answer here are the new technologies. First hand data about patients, tools, treatments and costs, obtained on the spot, can be transported quick and cheap via the Internet to everywhere. With mobile devices and standardized apps/ programs, a lot of paper work can be skipped and information can be processed immediately at the other side of the world. An example of software is EpiSurveyor of DataDyne. This software allows anyone to set up a worldwide, mobile-phonebased data collection system in minutes, for free. Conclusions and recommendations A main challenge in this marriage between the new technologies and global mental health is the need of a broad multi-sector collaboration. As A. Iluyemi and J.S. Briggs of the University of Porthsmouth analyzed : 'Project failure in ehealth and mhealth has been partly due to a lack of coherence between social and technological aspects of the system design and practiceâ&#x20AC;&#x2122;. According to the ITU, in their Tele-Health in India report, special additional attention needs the billing systems for services. It will save time and costs if from the start proven money transaction techniques are incorporated in the plans. For example a system like M-PESA, that enables customers to transfer money with their mobile phones.

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Since the awareness and knowledge of the medical staff in developing countries about ehealth and computers is low, the International Telecommunication Union recommends more training and capacity building in this field. They developed a special training course for participants from developing countries which was successfully launched in 2008. The WHO Global Observatory for eHealth advocates strongly for inclusion of eHealth courses within university curricula as well. According to the UN Foundation and Vodafone Foundation and A. Iluyemi and J.S. Briggs in their article 'Technology matters', during the design and implementation of the new technologies the end user must be kept in mind. Using the simplest available technology and adapting the plans to the ICT trends in developing countries. Low cost laptops like the One Laptop Per Child (OLCP) XOI device, which can withstand the harshest environmental conditions, have a long battery life and a wireless connectivity, are very useful in this context. There are a few important hazards with the use of Internet and mobile services. For instance: 'All info lays on the street' and commercial companies try to profit from the information and data available. Although most of the security problems encountered on the Internet are due to human mistakes, I think these privacy concerns must be addressed in all parts of the program designs and be a part in the education and supervision of health workers as well. There are solutions like encrypted data transport and codes/passwords, but this means extra technical knowledge and a consequent use in practice by all people involved. Extra caution is also needed in the use of the information derived from the web like articles/ blogs, research data/figures and advices and conclusions.

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Another concern comes from the IDRC. They think that the developing countries have both the most to gain and the most to lose from e-applications like eHealth. Because of the digital divide, there is a risk that the least developed countries will be excluded from the potential gains. And because a lot of funding, time and effort is needed to raise their health and eHealth infrastructure to the required levels, their debts can be increased or potentially diverting funding away from already stressed traditional health care delivery and support. Bill Gates, one of the keynote speakers at the mHealth Summit in November 2010, believes too that 'the greatest mHealth innovations will come not in the poor countries and not in the rich countries, but in middle income countries like Brazil, China and India'. So we must try to get the poorest countries on board. Initiatives like the healthcare divisions of a few big telecom companies like Telefónica, and global alliances like the ITU, the Global Observatory for eHealth, mHealth Alliance, and I.com etc., are also promising, but only the last one is specialized in eMental-Health.

of people who are struggling with untreated treatable mental health conditions, neglecting the eMental-Health applications in policies and plans is, I think, even a immoral deed. Thus, time for the wedding.

h ABOUT THE AUTHOR Roos Korste is a Psychologist with a practice in a primary care centre in the Netherlands, and founder of the in2mentalhealth Facebook page, Twitter account and blog which circulates global mental health information and advocacy. She is also a freelance trainer for MSF (Doctors Without Borders), training local mental health workers in areas of conflict or natural disasters. She was previously a Psychologist in the psychiatric hospital in Suriname, South America. She is a Web2.0 fan, and can be contacted on gipkorste@gmail.com. A longer version of this article is available at the author’s blog: Time for a wedding!

I hope this article is convincing enough. That, despite the hazards and obstacles, the new technologies are part of the solution of the mhGAP and can’t be ignored or left to the few Internet freaks in the field (like me). In the context of millions T I L T MAGAZ I N E j a n u a r y 2 0 1 1

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an Online Therapist

A Day in the Life of

Nelson, B. C. is a community of about 10,000 souls, nestled in the Selkirk Mountains, within the great range of Rocky Mountains. Although we’re in southern B.C. and only 2-½ hours’ drive from Spokane, Washington, we’re not exactly easy to get to. The nearest airport frequently cancels flights because of low cloud ceilings. The pass connecting us to cities to the east is the highest in this part of the province, with frighteningly steep drop-offs. In winter, heavy snowfalls can make the roads difficult and dangerous, or altogether impassible. Two winters ago when the power went out for several hours, my wife and I went to the neighbours to gather around their wood stove for warmth.

RALPH FRIESEN

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Our remoteness is also part of our mystique. It is said that this area holds a special healing energy. The veins of silver that lay embedded in the earth since time immemorial have been all but exhausted by mining beginning in the late 19th century, but now a new breed of prospectors speaks of crystal caves in the mountains. And local shops sell the crystal, valued for its healing energy. A large number of alternative healers practice their arts here—acupuncturists (my daughter is one), massage therapists, Rolfing practitioners, homeopaths, shamans, medicine men, time travellers. And three e-counsellors, of whom I am one, all of us affiliates with EAP provider Shepell•fgi. We don’t necessarily see our work as “alternative.” And yet we can appreciate why others might: our clients can be on the other end of the continent from ourselves; we neither see nor hear them; isn’t there something magical about this? My supervisor with Shepell•fgi, Cedric Speyer, teaches bilocation, the simultaneous presence of a person in two places. And he exemplifies this principle. While fully occupying the corporate world, with the demands of efficient and shortterm counselling that are part of it, he encourages what I would call a soul-connection with each person I work with via e-counselling. A quote he’s shared with me goes as follows: "A total restructuring of our knowledge is required once you accept this new definition of a person: A person is a relationship of which the other is infinite. What will the Psychology Department make of that?" (Sebastian Moore) And so it is, when I awaken each weekday at 6, in the darkness and cold of my bedroom, easing

out of bed with care so as not to disturb my stillsleeping spouse, when I bestir myself to switch on my laptop, make a cup of green tea, and settle into my home office chair, I first offer a short prayer. That I may know the presence of my client, the person, through his or her written words, and that he or she may in turn recognize my presence in my written words, and in this experience of mutual presence—which sometime seems to create a Presence with a capital “p”—solutions may be found, or even a measure of healing. As I offer myself to my counselling task in this way, I am mindful, at the same time, of the exigencies of everyday life. Although I may spend as much as an hour-and-a-half or, rarely, two hours on any given reply, my standard is actually to keep the reply within the usual bounds of a therapy hour. I may find myself writing in a way that is plain old garden variety employee assistance counselling, and needing to decide whether that’s okay, or whether I need to go deeper. The clients come with their range of issues, presenting anything from psychiatric issues to requests for advice on what to do with acting out children. Each morning I endeavour to pitch my work at the proper level. Generally it feels very intense, more so than face-to-face counselling, or in a different way. E-counselling doesn’t allow me to sit back while the client speaks; I must stay continuously focused, continuously attuned. Some practitioners can get into “the zone,” and sail along with ease, and sometimes I can, too, but I also have my times of sitting, thinking, writing, deleting, writing again . . . a sort of stumbling toward the precious goal of caring connection. > As I come to the conclusion of my first reply of the day, I hear my wife getting ready for the day downstairs; I wrap up my work and we go for T I L T MAGAZ I N E j a n u a r y 2 0 1 1

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our customary morning walk, down the hill and to Kootenay Lake Park. We chat as we walk along the lake shore, watching the everpresent Canada geese, or the cute little black coots paddling in groups. Part of each walk is held in silent meditation, and my mind rushes around to different problems and worries, and I watch that happening, letting go, letting go. Then we sing a morning song in German, in the tradition of our ancestors, walk up the hill back to the house, have a shower and breakfast— and I resume e-counselling. Another reply and it’s coffee time. After that break, still another reply or sometimes two, making three or four for the day, and that will be all. In the afternoon I have face-to-face clients, or I go to pick up my granddaughter—she’s in Grade One—at her school, and come home and play stuffies or dolls with her. The days are full. A bit of TV or reading in the evening, and then my wife and I do our gratitude practice—naming three things for which we’re thankful that day—and it’s off to bed. Often, I speak of my gratitude for the privilege of e-counselling, being able to practice this challenging, deeply rewarding science.

About the authoR Ralph Friesen is an online counsellor with Shepell•fgi, based in Nelson, BC.

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Cyber Supervision Anne Stokes

Over the next few issues, interspersed by other themes, this column will look at models of supervision and consider their appropriateness for online supervision. A question sometimes asked is whether f2f approaches should be adapted for online work, or whether new ones, specific to the medium, should be developed instead. My answer is ‘yes’! In other words, it is not ‘either/or’, but ‘and/and’. If I am comfortable using a particular approach f2f, what is wrong with using it online, with necessary adaptations? However, I would suggest that few of us use ‘pure’ models anyway, in counselling or supervision. So, consciously or unconsciously, we probably have developed a ‘new’ model. I’m beginning with Brief Interventions. For me, this

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approach to supervision works well, whether or not the supervisee works briefly with clients because ‘brief interventions’ is genuinely an approach, rather than a model. It is collaborative – which is what I hope is represented by the image at end! A criticism of online supervision concerns whether an hour of synchronous work is equivalent to a similar time f2f. I don’t want to get into that argument here; rather, I would say that a ‘brief’ focus helps to make good use of the time available, both synchronously and asynchronously. One of the basic tenets of brief work is respectful curiosity concerning the supervisee and the process of therapy. It aims to validate competence and resources, and to work to

defined goals. The latter might be set each session: ‘What are you hoping to achieve from this session/exchange of emails? It could also encompass a number of sessions: ‘I want to increase my ability to challenge appropriately online’. The supervisor checks frequently whether goals are being achieved. Many of ‘ways of being and working’ from SFBT are useful here, e.g. looking for exceptions to problems arising in the supervisee’s work or identifying pre-existing solutions. Generally, the focus is more on how the supervisee is working than on the client’s story. A helpful brief way of ensuring that the supervisor retains an overall sense of the supervisee’s work is for every client to be

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A Brief Approach to Online Supervision named occasionally, then rated on a scale of 0 -10 (10 being that everything is going as well as it possibly could). The supervisee writes briefly about what would be different if the next session moved up a point, and how they would recognise this. This enables the supervisee to recognise if they need to do or be something different, or do/ be more of the same.

Many supervisors already integrate brief â&#x20AC;&#x2DC;techniquesâ&#x20AC;&#x2122; into their supervision. For my part, from time to time, I find it useful to go back and see if I could do more in order to improve my online supervision.

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

Another criticism of online supervision is that it concentrates on competence and is not sufficiently challenging if there are problems or even unethical work. This neednâ&#x20AC;&#x2122;t be so, though the way of challenging may be different. It begins from a position of building on what is going well, and looking at the issues together as a dilemma, rather than taking the expert position.

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Ne wInnovations Best Practices for Videoconferencing Mark Goldenson To paraphrase Forrest Gump, video conferencing can be like a box of chocolates: you never quite know what you are going to get. The technology has improved a lot in recent years, but it is still not quite, as my mother would say, dummyproof. Video and audio can get out of sync, skip, or drop depending on different factors. Here are some best practices to optimize the experience for you and your clients.

Use a broadband internet connection of at least 384 Kilobits per second (Kbps) 384 Kbps is the minimum recommended speed per the American Telemedicine Association’s video conferencing guidelines for telemental health.

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This is common for modern broadband connections; you can check your connection’s speed for free at http://www. speedtest.net. If you are still using dial-up, it’s time to upgrade. :)

Close all other programs and tabs Video conferencing is a resource hog; it requires a good deal of computing power and internet bandwidth. You have a limited amount of both so closing all other programs and internet browser tabs helps increase capacity. Be sure to check the program tray in the lower-right of your desktop for any programs running in the background or when your computer starts.

Use a headset Echo is caused when the audio out of your speaker enters your microphone. You can prevent this by using a headset because the audio only enters your ears. Since a headset can look awkward, another option is to use a USB speakerphone that connects to your computer and has echo cancellation. I have had good experience with the ClearOne Chat50, which costs about $115. It’s pricey but worth it if you do a lot of video conferences.

Light your room well Just like a TV studio, a well-lit room is needed for video to broadcast well. Ideally the light source should be in front of you

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and illuminate back. A powerful desk lamp in front of your desk can work.

Consider using only one video stream If you are in a 1:1 or group video session and experience problems with syncing or skipping, consider broadcasting just one video stream from you or your client. This is not ideal but can be better than poor two-way video or the phone alone.

is not ideal because the video and audio may not sync, but virtually everyone has a phone and audio is usually the more important channel.

Send setup instructions beforehand To help prevent issues during session time, send a list of tips before your session. These can include a link to your virtual room for pre-session testing, a summary of what to expect in the session, and advice like the above.

Consider the phone for audio back-up If your video stream is reasonable but your audio is problematic, consider using the phone for your audio and the internet for your video. This

Happy ! g n i c n onfere

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

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Marketing Toolbox Susan Giurleo

A Social Media Marketing Plan for 2011 Where do your potential clients look for health care information? According to Susannah Fox of the Pew Internet Project, 93% of all teens and 79% of all adults used the Internet in 2010 and 60% go online to find health information. With the numbers of people using social media to share their health experiences, we need to be where the public is and show up in the spaces they “hang out” if we hope to grow our clinical practice. This is especially true if you are developing a practice that includes online therapy. Your potential clients will be comfortable with online activities and will be seeking support using Internet search and social media tools. Initially, social media can seem overwhelming and complicated but the truth is there are a lot of ways to use social media (such as blogs, Facebook, Twitter, LinkedIn, etc) to market and grow a practice. I’ve been building my online and offline client services via social media for about 4 years. Let me give you a simple, straightforward way to organize your social media marketing for 2011. 54

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A Simple Way to Organize Your Social Media Marketing for 2011 1. If you don’t already have one, start a blog. The blog should be integrated with your website. Plan to update the blog at least once a week. Blogging more often can improve your marketing outcomes, but once a week is sufficient as you get started. 2. Set up a Twitter account and follow people who are talking about subjects related to your clinical specialty. Use tweets to tell people about your blog posts (driving traffic to your website/blog). And tweet information relevant to your ideal clients. For example, if you support women with stress, it’s appropriate to tweet information related to how to manage stress, links to magazine articles, research or other blog posts on the topic of stress, etc. Make time to have short conversations with people. 3. Develop a Facebook business page and share similar information on your wall that you share on Twitter. Sometimes I mix up what I share on which social media site, so if someone follows me on both Twitter and Facebook they are always getting new, fresh ideas. A Facebook business page is not the same as your personal page. People can “like” a business page without sharing any of their personal information on your wall and you can isolate your personal account from current/former clients and potential clients. That’s it! Doesn’t that seem much more manageable than trying to stay active on all sorts of networking sites?

What’s the Point? Often people ask me why they should engage in all of this online socializing. The truth is, you’re building relationships that will benefit your business growth. Some of these relationships will be with potential clients. You’ll also be networking with colleagues who can refer to you, your services and products. Today people are more and more comfortable connecting with others online. They view many of their online relationships as similar to those they have offline. People will more likely do business with health care providers they can “vet” ahead of making an appointment and will increasingly expect to be able to see how you work and your professional philosophies before they engage in a working relationship. Social media is not a place to engage in therapeutic relationships, but a forum to engage in a similar way as you would at a community networking meeting or health information fair. So, go be where your clients are and get set up online and in social media. Get started and experiment with what works for your specialty and ideal clients. Social media can be fun and help you reach your business goals in a low cost, effective way. Susan Giurleo, Ph.D. manages www.bizsavvytherapist.com, bringing mental health support to people via social media and online technologies. She is based in Massachusetts, USA T I L T MAGAZ I N E j a n u a r y 2 0 1 1

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Online Therapy Institute Verification When you see this seal on a website it means Online Therapy Institute has verified this website as compliant with Online Therapy Instituteâ&#x20AC;&#x2122;s Ethical Standards. We will display thumbnails of everyone who has become verified since the last issue.

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t to At

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Upcoming Dates Wednesday, January 12, 2011

OTI Chat Room

http://www.onlinetherapyinstitute.com/chat-room/

> SECOND LIFE 1:00 PM EST > CHAT 6:00 PM EST

Thursday, February 10, 2011 > SECOND LIFE 10:00 AM EST > CHAT 2:00 PM EST

Tuesday, March 8, 2011

OTI Conference Centre in Second Life!

http://slurl.com/secondlife/jokaydia%20II/109/52/1002

> SECOND LIFE 9:00 PM EST > CHAT 3:00 AM EST (morning of the 8th)

T I L T MAGAZ I N E j a n u a r y 2 0 1 1

TILT â&#x20AC;&#x201C; Therapeutic Innovations in Light of Technology

Books can be dangerous. The best ones should be labeled "This could change your life." ~Helen Exley

Love For the

Books of

T I L T MAGAZ I N E J a n u a r y 2 0 1 1

Wellness & Writing Connections: Writing for Better Physical, Mental, and Spiritual Health John Frank Evans (Editor) Two of the top experts in the field of writing and wellness join with 15 others to show us how writing is used to heal physical illness, emotional trauma, and spiritual pain. James Pennebaker, who was the first to research the connection between writing and wellness, and Cindy Chung present 25 years of experiments that demonstrate the benefits of writing to heal and point the direction for more studies. Luciano L'Abate discusses his use of writing and discusses how the techniques can be used to significantly lower health care costs. Debbie McCulliss shows how she uses writing to engage us, so we are able to examine an experience, compare it to other experiences, and apply the new insights to ourselves. Leatha Kendrick looks at finding our true voice to lead us to recovery. Gail Radley presents techniques to move us from feeling like a victim to finding solutions. Fran Dorf tells how she turned her grief into a best-selling book (Saving Elijah) and shows us how to use fiction to ease our pain. Emily Simerly gives us six starter chapters to show how we can adapt to our lives. Belinda Shoemaker proposes that the act of adding craft and style to our writing increases our understanding of what we have written. Noreen Groover Lape and Kristin N. Taylor continue Shoemaker's theme by describing their interaction as student and teacher, improving Taylor's writing and understanding. Diana M. Raab shares tips about her journaling that we can use to keep our precious insights from slipping away. Julie Davey shows how we can use the Writing for Wellness program she has been leading for cancer patients at City of Hope for the past seven years. Sara Baker reminds us that we can write about our hurts in ways that don't retraumatize us by telling it slant. Angela Buttimer describes the Cancer Wellness groups she leads at Piedmont Hospital and teaches us how to use some of her techniques.Austin Bunn describes the Patient Voice Project to teach expressive writing to the chronically ill. Lara Naughton champions the Voices of Innocence project, which demonstrates how we can help non-writers create written works that aid spiritual and emotional healing.

Virtual Worlds (Learning in a Changing World) Judy O'Connell and Dean Groom Each year there are more and more avatars in rich virtual environments. These immersive worlds – where the world within the screen becomes both the object and the site of interaction – are on the increase, matching the promise of technology with the creative minds of our students. Educators, keen to incorporate the evolving literacy and information needs of the 21st century learners, will want to understand the opportunities provided my MUVEs MMORPGs and 3D immersive worlds, so as to be able to create more interactive library, educational and cultural projects. The challenge is to accept that these virtual worlds are here to stay and that schools can, and should, embrace learning in interactive environments. Virtual Worlds will provide the knowledge, inspiration and motivation to get you started.

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

P.O. Box 19265 Springfield, IL 62794-9265

B OOK S AVINGS (on separate titles only)*

• Bryan, Willie V.—THE PROFESSIONAL HELPER: The Fundamentals of Being a Helping Professional. '09, 220 pp. (7 x 10), $51.95, hard, $31.95, paper.

Save 10% on 1 Book ! • Save 15% on 2 Books ! Save 20% on 3 Books !

• Correia, Kevin M.—A HANDBOOK FOR CORRECTIONAL PSYCHOLOGISTS: Guidance for the Prison Practitioner. (2nd Ed.) '09, 202 pp. (7 x 10), 3 tables, $54.95, hard, $34.95, paper.

COMING SOON! • Douglass, Donna—SELF-ESTEEM, RECOVERY AND THE PERFORMING ARTS: A Textbook and Guide for Mental Health Practitioners, Educators and Students. '11, 232 pp. (7 x 10), 6 il., 5 tables.

• Kocsis, Richard N.—APPLIED CRIMINAL PSYCHOLOGY: A Guide to Forensic Behavioral Sciences. '09, 306 pp. (7 x 10), 4 il., 2 tables, $65.95, hard, $45.95, paper.

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

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

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

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

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

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

easy ways to order!

PHONE: 1-800-258-8980 or (217) 789-8980

FA X

FAX: (217) 789-9130

EMAIL: books@ccthomas.com

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

Charles C Thomas • Publisher, Ltd. P.O. Box 19265 Springfield, IL 62794-9265

Web: www.ccthomas.com Complete catalog available at www.ccthomas.com or email 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 *Savings include all titles shown here and on our web site. For a limited time only. When ordering, please refer to promotional code TILT1110 to receive your discount.

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Wo rk fo rce C ar eer C o ach Facili ta tor

120-hour online program prepares you to help others find jobs and new careers

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Students earn up to 15 CEUs

www.tesc.edu/noncredit (888) 442-8372

ERE H D A R U YO

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

In our MARCH issue... 99 Mieke Haveman tells us about her experience in training to be an online therapist 99 Bob Acton discusses the Computerised Cognitive Behavioural Therapy (CCBT) package Beating the Blues 99 Casey Truffo tells us about creating multiple streams of revenue. 99 A Day in the Life of an Online Therapist: Kylie Coulter, www.lifechoices.net.au, NSW, Australia 99 And also much more, including… member’s responses to this month’s Ethical Dilemma, a new cartoon from Wounded Genius, a new column on Online Coaching from Lyle Labardee, and find out who is newly Verified by the Online Therapy Institute!