TILT Magazine (Issue 4) by Online Therapy Institute

Issue FOUR March 2011

PAGE 24

An Ethical Framework for the Use of Technology in Coaching

PAGE 9

Online Coaching and Developing Relationships

PAGE 42

From Therapist to Coach 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 4, March 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 Melissa Bochet Associate Editor for Research Stephen Goss Associate Editor for Innovations Mark Goldenson Associate Editor for Supervision Anne Stokes Associate Editor for Marketing and Practice Building Susan Giurleo Associate Editor for Film and Culture Jean-Anne Sutherland Associate Editor for Legalities Jason Zack Associate Editor for Coaching Lyle Labardee Advertising Policy The views expressed in TILT do not necessarily reflect those of the Online Therapy Institute, nor does TILT endorse any specific technology, company or device unless Verified by the Online Therapy Institute. If you are interested in advertising in TILT please, review our advertising specs and fees at www.onlinetherapymagazine.com Writer’s Guidelines If you have information or an idea for one of our regular columns, please email editor@onlinetherapymagazine.com with the name of the column in the subject line (e.g. Reel Culture). If you are interested in submitting an article for publication please visit our writer’s guidelines at www.onlinetherapymagazine.com.

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

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Features 9 Online Coaching and

Developing Relationships

24 An Ethical Framework for the Use of Technology in Coaching

42 From Therapist to Coach

Issue i n e v er y

6 News from the CyberStreet 14 Research Review 20 Dilemma: Reader Responses 22 What Would You Do?! 23 Wounded Genius 35 Reel Culture 37 Legal Briefs 40 Technology Enhanced Coaching 50 A Day in the Life: Therapist 54 A Day in the Life: Coach 58 CyberSupervision 64 New Innovations 68 Marketing Toolbox 70 Get Verified! 71 OTI Open Office Hours 72 For the Love of Books 75 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 fourth Issue. We are excited to introduce a special theme to this month’s magazine – Online Coaching. We are pleased to be launching the Online Coach Institute (OCI), our sister website, and our aim is to bring all of our global experience and resources in the use of technology to the coaching profession. We announced our partnership with the Institute of Life Coaching Training (ILCT) in our last issue. ILCT’s longstanding history as the leading, international provider of coach training and online coaching resources for counselors, psychologists, therapists and other helping professionals make it an ideal partner for OTI. This special issue of TILT reflects our goal to reach out to all helping professions to work with technology in an ethical way. We have three special coaching articles for you. We publish our Ethical Framework for the Use of Technology in Coaching, written with Lyle Laberdee of Life Options Inc. We also welcome Lyle as our new Associate Editor for Online Coaching, and appreciate his frank views on the topic in his new column. Lyle’s agreement with the International Coach Federation’s view that working online can only be “valid” if used in a supporting role – what he calls Technology Enhanced Coaching – is a debate that we look forward to having, and we encourage all our readers to join in at the OTI and OCI forums. Yolanda Wysocki tells us of her own experience in being an Online Coach, and how to build strong relationships with coaching clients online; and Casey Truffo describes the journey from Therapist to Coach. Our books section also has a coaching theme, as does our new Coaching Day in the Life feature as we welcome Lora Sasiela – a Psychotherapist turned Financial Coach – to talk us through her day. Stephen Goss discusses Coaching Research, and finally our own resident cartoonist Wounded Genius gives us the unique client take on the differences between therapy and coaching. 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 now open debate and discussion around the profession of Online Coaching with the launch of the Online Coach Institute. All our other regular columnists are here, with useful and entertaining comment on online supervision, marketing; film culture; legalities; and new innovations – this month with commentary from John Grohol from PsychCentral. 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 Five. We also feature Kylie Coulter who tells us about her Day in the Life of an Online Therapist. We hope you enjoy our fourth issue, whatever professional world you inhabit. All feedback is heartily welcomed at the OTI/OCI social network - longer responses to articles can also be submitted to editor@ onlinetherapymagazine.com, and will be published in the next issue.

Managing Editors T I L T MAGAZ I N E m a r c h 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 and forum News… Here is a glimpse of what is going on… get a taster and then head to www.onlinetherapyinstituteblog. com, the member blogs at www.onlinetherapysocialnetwork.com, and the OTI forums on the homepage of the Social Network! DeeAnna shared her thoughts on how to handle a crisis online, discussing the use of assessment tools such as the SAD PERSONS Scale. She also discusses how members can use the OTI Online Consultation Forum – an alternative to our free monthly Open Office Hours in chat and Second Life if you have a business question or a clinical issue you need individual input on. On the social network blogs, John Wilson tells us of his upcoming events streamed online; Stephen Goss gives those of us in the UK valuable information about how data control rules affect us when working online; and Francis Goldberg discusses reports on how abortion can affect mental health and also working against transgender discrimination. DeeAnna discusses working with videoconferencing, posing the question – is it really all the rage? Forum discussions and debates include liability insurance for working at a distance; when asking for permission to use other people’s content on websites is appropriate; and essential information for clients that should appear on websites.

Member news… Online Counseling A Handbook for Mental health Professionals, 2nd edition is published (Kraus, Stricker & Speyer 2011), with chapters by Cedric Speyer (co-editor) and John Yaphe (Working with Email) and DeeAnna Merz Nagel and Kate Anthony (Working with Chat). Visit http://www.elsevierdirect. com/ISBN/9780123785961/Online-Counseling for more information. Financial therapist and founder of Financially Smitten is thrilled to be featured in the February issue of Glamour Magazine. To read the "My Dirty Little Money Secrets" article, click here. We are glad to be featuring her in this issue of TILT as well! T I L T MAGAZ I N E MARCH 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.

Spiritual Autobiographer and author Alisa E. Clark introduces a 2 Part Video Series, Your Story, My Story. View the series at http://www.vimeo.com/ user5829963 and learn how technology can help you share your story. Visit www.journeyoncanvas. com to learn more about spiritual autobiography. Marina London will lead a one day workshop "Crash Course in Social Media for Mental Health Professionals" on Friday, April 8, 2011 in Seattle, Washington. For more information, and to register read the flyer http://www.eapassn.org/files/ public/seattleflyer0411rev.pdf Joanna Poppink, MFT, a Los Angeles psychotherapist specializing in eating disorders and women's development, is happy to announce the publication of her self-help book: Healing Your Hungry Heart: Eating Disorder Recovery for Women, which will be out August, 2011. Please visit http://amzn.to/gqNy48

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Ros Share has recently published “LUpus Patients Understanding & Support”. Systemic Lupus Erythematosus is an incurable autoimmune disease of uncertain aetiology. In 2000 LUPUS was established to provide free information for patients, carers and health professionals; and to provide free online psychological support. Please visit https://www.morebooks.de/store/gb/book/ lupus-patients-understanding-and-supportlupus/isbn/978-3-639-30263-9

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Online Coaching and Developing Relationships BY Yolanda Wysocki Many of us with a counseling background have a similar reaction to the thought of online coaching...”but you miss so much of the nuance, cues and responses that tell so much,” or some variation of that theme. In face-to-face work, we have access to the full range of subtle to obvious reactions; a quick twitch of an eyelid, a change in posture, drop in eye contact; tears silently streaming down a face; energy shifts...we each know the huge variety of available cues when a client sits in front of us. The first big adjustment happens as access to those cues decrease when we switch to telephone coaching. We lose the visual, but still keep auditory cues like voice intonation, pitch, pauses, quavering, etc. We listen to the specific words, turns of phrase, descriptions that offer a lot of information. Despite balking at what has been lost, phone coaching is still rich with information and possibility. So imagine when we make the move to online coaching–– which is coaching where in my experience the majority of contact happens online as asynchronous email, instead of phone or in-person. Most of what we have counted on--the visual and auditory cues-- is gone! This is why so many Life Coaches I meet are very reluctant and pessimistic about the idea of beginning online work.

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TILT – Therapeutic Innovations in Light of Technology

So why would anyone choose to do online Coaching given its disadvantages? The main reason is convenience. Clients can go online in the middle of the night, use any computer and communicate with their Coach. They won’t get an immediate response but it’s quite an advantage for very busy people to be able to access Coaching when scheduled appointments may be highly inconvenient. Coaches can work anywhere around the world and still maintain a practice. That is the number one reason clients choose this medium. Well, how do we develop strong online coaching relationships?

We may lose the customary cues, but gain something else however: the written word itself. Each of us develops a written voice. A person’s personality and energy comes through in the way we write. Just as in face-to-face work, we can always use the same or similar language as our clients, in phrasing, matching sensory systems, and rephrasing to develop a bond. Also, notice the way I have separated different ideas into related paragraphs. What do we learn about a client who writes two or three pages every day versus one who writes a paragraph every week or so? The ones we have to pull information out of versus those that seem to pour information randomly and in a stream of consciousness manner? What do we learn about someone who doesn’t edit, writes in long run-on sentences in one 3-page paragraph? What do we learn from specific words, the language used? I have a client who quotes lyrics from parts of songs to express how he is doing. Everything is information. With writing, the pace is slower and there is more time to develop safety and trust. That can be an obstacle as well as a strength. Although my work is primarily online, my preference is to do an initial call for intake to move through a lot of information,

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make a strong connection, and develop goals. The rest of the work from that point goes more smoothly. Not everyone prefers that, however, including clients. In those situations, we can still develop strong connection. We lose spontaneity and flow that occurs in conversation but what we gain is spaciousness. We can stop to ponder, consider beyond first impressions and reactions to deeper truths, beliefs, obstacles, wounds, and those things that sometimes take time to emerge from deeper layers. I speak not only of hearing the client more deeply, but also our own wisdom, reactions, and truths that also occasionally need time to develop and clarify in a manner that illuminates the discussion. We can take time to develop appropriate metaphors, paradigms, and perspectives that touch deeper truths, and therefore are more likely to promote real shifts. I have also taken time to search the right quote, an article I have read, or an exercise I can offer along with my response. Another advantage of the written word is being able to go back and copy and paste the client’s exact words even months later when they are running into obstacles or revisiting the importance of what they are working on. The ability for people to read their own words after they have been forgotten is a

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powerful and very useful tool that gets their attention and reminds them of their own truth, fast. A slow pace can serve us over time. Some of my clients have stayed for a few years, and moved into increasingly intimate and/or painful work...dealing with death of a parent or spouse, severe illness, or preparing to divorce their longterm spouse, for example. The bond and trust that develop over a long period seems unlikely online, but the depth and range of work that can and does happen defies expectation, and is a testament to the ability and power of one soul

touching another with/despite technology. But what about obstacles and difficulties? There are certainly matters that need to be considered and addressed that arise in online coaching that differ from phone or in-person work. Over time, I have learned it is wise to bring up several issues early on in developing the coaching relationship. One is to make sure both parties agree on the parameters of coaching, what it is and is not. Many people are still confused by the terms and

have vague ideas about Coaching, and they come into it from a wide variety of paths. I have been thought of, and engaged with, as a friend, a sounding board, a counselor, consultant, someone to talk to. These are useful and I enjoy these roles and being thought of in these ways. But I let people know from the beginning that creating change together is the purpose for the relationship we are engaged in. That involves tasks, and taking steps toward those changes. Because we all send out some form

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TILT – Therapeutic Innovations in Light of Technology

of initial information exchange packet, eliminating confusion and answering all questions and concerns at the beginning sets a very positive strong foundation, and eliminates much frustration that can develop on both sides if not clearly delineated. This is also a great opportunity to refer those folks who are looking for something other than Coaching onto resources that may be a better match for them How often you contact each other and who will initiate the contact is not a problem or issue in phone or faceto-face but the dynamics change in Online Coaching. Developing tasks together, checking in around progress and obstacles requires a back and forth exchange of several emails before we can establish next steps together. Then there may be a lull as they try out those new tasks before the next regular check–in. Emailing questions also contributes to far more fluid boundaries and timeframes with many clients. Ascertain a reasonable timeframe that your client can expect a response from you, and vice-versa (some Coaches include Instant Messaging during

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certain hours, but I have not). How to bill for this becomes necessary to consider and have a dialogue around. Not surprisingly, my clients are incredibly busy people. What happens when folks are working 10-14 hour days or a project gets thrown at them with very tight deadlines? One problem I frequently run into comes up when people get too busy––they

don’t respond to emails. It’s far easier to ignore an email than a face-to-face or even a phone appointment. When they have no time to focus on their lives; when clients didn’t do the agreed upon task, the emails stop, and momentum gets lost. What would help prevent that? Every Coach will work together with their client to find solutions that

work for them, but plan ahead for those times. Make it part of the setting foundation phase. Work together to create a plan knowing the issue will inevitably arise. Developing guidelines and agreements together regarding whether to put Coaching on hold temporarily, increase the length of time between correspondences, or change focus briefly until the stress lessens are all options my clients have agreed to. One example of an agreement made with a client is: “No matter what is going on, even if I had no time to work on my goals, I will email my coach the second and fourth Tuesday of the month, even if it’s just to let her know I am swallowed up by work, or need to change the focus temporarily to Coming out of this Alive.” She put it in her appointments and we kept moving fluidly until she completed the project. And we did shift the focus of our work to easing her stress and taking care of herself in small daily increments. The key is to plan ahead for those busy times. Hopefully momentum will continue, and usually it is easy to

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get going again with regular clients I have known for a while or those who are pretty consistent in contacting me. But at times things grind to a halt. Use humor as much as you can to get clients’ attention and to reengage. I have sent emails only with a subject line like “Hellooooo. Anybody home?” or whatever I think may get their attention. I may initiate a call, or have more frequent contact until energy is moving again. When Coaching has been going on for a while, the larger scope of the goals can get lost. This can certainly be true in any type of Coaching but I find it too easy with email to hone the focus down and down so much that I, and the client, forget the original goal. It’s very useful to regularly step back to review the larger picture...Why are we doing this and where are we going? Where did we start and how did we break it down to this particular task (like organizing a closet, or filling out a whiteboard). The image of seeing a house from the inside, and regularly stepping out of the house, looking at it as if from an airplane window, is one I like to use. Zooming in; zooming out. Otherwise it can seem like all we are doing is focusing on getting through tasks and lose sight of the larger picture and the values driving the change. Also, play and be creative...send links to YouTube videos, great websites and blogs, poems, articles, anything that will inspire learning from different points of view, uses different learning modalities, and will get and keep your clients’ motivation and energy engaged. Finally, be generous with your responses; hold your clients in your heart. It is too easy, as we all know in this techno frenetic age, to become words and syllables on an ever-smaller screen. Let’s always remember as we step into Online Coaching that there is a whole human being on each side of those monitors, able to be reached on a heart and soul level. n

Tips for Online Coaching: •

Everything is information.

•

Use the same sensory system as your client.

•

The skills needed to develop a safe bond are the same: listening without judgment, paraphrasing, and positive acceptance.

•

Set agreements early on, such as how often they will contact you, and how to keep momentum going when life gets busy.

•

Before responding, ask yourself what are the tone, request, and need in this specific communication?

•

Slow down, reread, and proofread before sending anything.

•

Use humor to engage and keep connection.

•

Move back and forth between specific tasks and larger picture to keep Coaching alive and tasks in perspective.

•

Be creative, playful; take advantage of all that is available e.g.YouTube; blogs; website links, etc.

About the author Yolanda Wysocki, MA, PCC, completed her MA in Consciousness Studies, her Professional Certified Coach certification through the Institute for Life Coach Training (ILCT), and is getting ready to complete the MCC credential. She currently works as an online Coach, is expanding her own business, The Art of Life/Coaching, and is based in Eugene, Oregon.

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TILT – Therapeutic Innovations in Light of Technology

Research Review

Online Coachin – the Fu Reflecting the breadth of uses of the term, examination of research into online coaching reveals studies of a broad range of interventions in contexts that are equally diverse. Anecdotally, most focus on educational and health settings, with fewer studies on executive or business coaching being listed in the research literature, although there are clear indications on things like the return on investment (ROI) for coaching in general, some of which will include online delivery of services. Overlap with counselling and psychotherapy research can allow for at least some transferability of that larger evidence base to the realm of personal or life coaching but it remains clear that there is much potential for sound empirical data to be added to the existing literature in all these areas, with valuable results for the whole field. Comprehensive reviews of the evidence base – especially those looking specifically at technologically mediated methods – remain to be carried out for several types of coaching, although there are some exceptions. The situation is partially obscured by the very prevalence, diversity and seemingly widespread

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acceptance of distance provision in coaching, with a number of studies incorporating reports of technologically mediated interventions of one kind or another without necessarily highlighting them sufficiently to be located by the usual systematic search methods, meaning that useful evidence can slip under the radar. Nonetheless, interesting features of the online coaching world still emerge from the body of work available at this time and a miscellany of exemplars is noted here. Prevalence is high The International Coaching Federation (ICF) reported as early as 1998 that, among a sample of 210 coaching clients, ‘by far, most personal coaching is done virtually’ (ICF, 1998, p.2). Some 45% of clients already used email services and far more used telephones, quite apart from other technologies, while only 35% had sessions face-to-face. The authors noted that this contrasted with coaching in corporate environments which they believed to be predominantly provided face-to-face. In a more recent ICF study (with different characteristics, not directly comparable with the earlier work), data from 5415 coaches from 73 countries suggested that, while technologically

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S t e p h e n G o ss

ng Research uture is Bright! mediated communication could be seen as supplementary to face-to-face work in some instances, distance provision comprised nearly half of respondents’ activity. 42% was conducted by telephone, not counting other technologies. Among respondents from North America, distance methods were reported to be more common than face-to-face work (ICF, 2008). Where data is publicly available, online coaching also appears to have encouraging outcome data in several settings. For example, in education, Pavey-Scherer (2009) found that online coaching improved perceived competence among teachers – a finding replicated in several studies investigating variations on the coaching approach for both students and teaching staff. Gentry et al. reviewed the literature on coaching in educational settings in 2008, reporting that ‘technology-mediated mentoring has strong potential for overcoming barriers of accessibility and cost-effectiveness associated with traditional on-site mentoring’ (p. 339). Despite identifying variable uptake of some services as an issue, this synthesis of 14 studies (selected from a much larger pool of studies of

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TILT – Therapeutic Innovations in Light of Technology

educational coaching in general), found that ‘those who accessed the resources generally reported having a positive experience, reporting shifts in their attitudes towards instruction and changes in instructional practices’ (p. 339). However, the authors also noted the need for more experimental or quasi-experimental studies measuring change in student attainment to add to the largely qualitative evidence available at the time of their review. In business settings, Fielden and Hunt (2006), reported on the potential for online coaching to reduce barriers to entrepreneurial activity for women in particular, by improving access to business support services (in which women are generally underrepresented) and addressing issues of social background, confidence, childcare responsibilities and ethnicity. A range of other studies of coaching in the workplace are generally supportive, again revealing diversity of methods. Using a case-study design to investigate a management development programme for the Royal College of Nursing in the UK, Collett (2008) reported that distance coaching improved utilisation rates by up to 40% among her sample, albeit a small one. There have been numerous studies of coaching in healthcare, either for practitioner development or, perhaps more frequently, as a means of helping patients manage their condition and its treatment. Social networking tools, such as forums, have been shown to further increase treatment

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adherence rates over and above improvements from other distance interventions that themselves have been shown to fare well when compared with face-to-face work alone in several studies (eg Richardson et al, 2010). Entirely automated coaching systems in health care have also shown positive effects, for example in smoking cessation (eg Balmford et al, 2008) and migraine control (eg Sorbi et al, 2007) among others. A particularly encouraging example for healthcare coaches (although conducted by personnel working for the provider concerned) involved over 174,000 people predicted to have high care costs, including patients who seek unnecessary – and expensive – face-toface consultations too frequently. The study reported an impressive 1:4 cost-benefit ratio, suggesting that the coaching paid for itself four times over within 12 months, through carefully targeted distance coaching. Hospital admissions were reported to have been reduced by 10% (Wennberg et al, 2010), constituting a major saving in itself. If these findings are confirmed by studies elsewhere, health care systems around the world should be alerted that distance coaching for patients has the potential to save significant amounts in their increasingly pressured budgets. If similar results were demonstrated in other settings, and especially where published experimental and comparative studies become more common, the future looks very bright indeed for online coaching. n

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References

Balmford, J., Borland, R. and Benda, P. (2008) Patterns of Use of an Automated Interactive Personalized Coaching Program for Smoking Cessation. Journal of Medical Internet Research, 10(5) 54. Available at: http://www.jmir.org/2008/5/e54/. Accessed 7th February, 2011. Collett, K. (2008) A case study on the effectiveness of telephone coaching . Available at: http://www.icoachacademy.com/media/research/A%20case%20 study%20on%20the%20effectiveness%20of%20 telephone%20coaching.pdf. Accessed 7th February, 2011. Fielden, S. and Hunt, C. (2006) Challenges and opportunities â&#x20AC;&#x201C; The case for online coaching. In D. McTavish and K. Miller (Eds) Women in leadership and management. (pp. 163-180). Northampton, MA, US: Edward Elgar Publishing. Gentry, L., Denton, C and Kutrz, T. (2008) Technologically-based mentoring provided to teachers: A synthesis of the literature. Journal of Technology and Teacher Education (JTATE). 16(3): 339-373. ICF (1998) Client Survey Results and Press Release Analysis of 1998 Survey of Coaching Clients by the International Coach Federation. Available at: http:// www.coachfederation.org/research-education/icfresearch-portal/research-portal--reports/. Accessed 7th February, 2011. ICF (2008) International Coach Federation Global Coaching Study. Available at: http://www.coachfederation.org/includes/docs/064GlobalCoachingStudy ExecutiveSummary2008.pdf. Accessed 7th February, 2011. Pavey-Scherer, D.L. (2009) The effects of online coaching on instructional consultation skill development and treatment process integrity. Dissertation. Univer-

sity of Maryland. Abstract available at: http://drum. lib.umd.edu/handle/1903/8765. Accessed 7th February, 2011. Richardson, C.R., Buis, L.R., Janney, A. W., Goodrich, D.E., Sen, A., Hess, M.L., MehariK.S., Fortlage, L.A., Resnick, P.J., Zikmund-Fisher, B.J., Strecher, V.J. and Piette, J.D. (2010) An Online Community Improves Adherence in an Internet-Mediated Walking Program. Part 1: Results of a Randomized Controlled Tria. Journal of Medical Internet Research, 12(4) e71. Available at: http://www.jmir.org/2010/4/e71/. Accessed 7th February, 2011. Sorbi, M.J., Mak, S.B, Houtveen, J.H., Kleiboer, A.M. and van Doornen, L. (2007) Mobile Web-Based Monitoring and Coaching: Feasibility in Chronic Migraine. Journal of Medical Internet Research, 9(5) e38. Available at: http://www.jmir.org/2007/5/e38/. Accessed 7th February, 2011. Wennberg, D., Marr, A., Lang, L., O'Malley, S. and Bennett, G. (2010) A Randomized Trial of a Telephone Care-Management Strategy. New England Journal of Medicine. 363: 1245-1255.

Stephen Goss, Ph.D. is Principal Lecturer at the Metanoia Institute, and also an Independent Consultant in counselling, psychotherapy, research and therapeutic technology based in Scotland, UK (http://about.me/stephengoss).

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

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Sam Weily, a combined Masters and PhD student at Monash University in Melbourne, Australia, is seeking practitioners of online counselling to undertake a semi-structured interview (4560 min). The interview looks at process and practical factors of online counselling in realtime chat, email and web forum moderation (no skype or video conferencing). The research looks to understand how process and practical factors are formed differently in the online medium. For more information:

EMAIL SAM

Research Call Courtney Holmes, a Ph.D. candidate in Counselor Education at the College of William and Mary, is recruiting participants for her dissertation study (approved by W&M's IRB committee). She is looking for the following: • adults (over 18), • currently in online therapy (telephone, email, synchronous chat, or videoconferencing), • who have seen their current counselor for at least 3 sessions The study will compare online therapy to more traditional, face-to-face counseling. As such, she is looking for participants who are currently active in online counseling. If you are interested in participating please follow the link below, which will explain the study with more detail. Research website http://wmpeople.wm.edu/site/page/cmholmes EMAIL COURTNEY cmholmes@email.wm.edu

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Samuel.weily@monash.edu.au

Charlotte Parker, a graduate student at Smith College School for Social Work, is conducting a research study that explores clinicians’ experiences of using videoconferencing technology to provide mental health services for her Master's thesis. She is seeking social workers who would like to share their experiences of using videoconferencing technology in practice. Participants will take part in a 45-75 minute interview over Skype. If you hold a Master’s degree or Doctorate in social work and have used videoconferencing technology to provide services, you are eligible to participate. Services provided could include (but are not limited to): • • • • • • •

individual therapy; group therapy; family therapy; crisis assessments/interventions; assessment & diagnosis; disposition planning; any other way that you have used videoconferencing technology to provide services to clients.

For questions, more information, or if you are interested in participating, please:

EMAIL CHARLOTTE

charlottepar@gmail.com

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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 a therapist hiring a room in a local community centre, which houses a doctorâ&#x20AC;&#x2122;s 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/cell phone 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?!

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Now this is an interesting dilemma for client and therapist, do either of them use their foursquare account to 'check in' at the therapy location. Anyone can set up their office as a location on foursquare, so we might not get a choice! I usually use foursquare when I am traveling, feels like fun to check in at railway stations, airports and hotels, partly as I have time and partly as it's a conversation starter on the social networks and I am in the mood for a chat. When I check in, foursquare posts the location along with my comment to my Facebook and twitter accounts. Then as clients we might meet those who also visit our therapist, we could compare notes on sessions and deliver feedback to our therapist via social networks. But do I want to be approached in this way, am I vulnerable as a client opening myself up to this kind of contact? And as a therapist foursquare could show when I am in the office, open up channels of feedback from clients. But could also show that I have very little work, or that I am overworking! There are clearly ethical and very personal dilema's around confidentiality and disclosure and it gets me thinking of mental health and the experience of therapy, whichever side of the couch we might be sitting, is it still one of embarrassment and exposure? Social networking opens up unparalleled opportunities for contact and needs careful thinking about.

Reply by

John Wilson

My own strategy for dealing with this would be to address it early in treatment and let clients know of how much information they may be sharing with others if they check-in manually or passively. My own social media policy addresses LBS issues since clients may unintentionally be letting others know they have a weekly appointment at my office (even though I don't list my office as a check-in point). I would also feel it important for me not to check-in when I am working in a professional capacity, as this may indicate to others that I am providing health care services at a particular location. If others were to check-in from this same location, they may be indicating that they are under my care at this time which could be an unintentional disclosure of health related information. This is all tricky stuff, especially now with "Places," enabled on sites like Facebook.

Reply by

Keely Kolmes T I L T MAGAZ I N E MARCH 2 0 1 1

TILT – 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 Institute’s social network. In the following issue of TILT, we shall publish a selection of comments about what YOU would do when faced with the dilemma, as well as our own considerations about what the issues are.

What Would You Do? dilemma You are a life coach. For years you practiced as a psychologist and now you practice exclusively as a life coach. Your coaching client has tweeted you the following: @lifecoachdiva I am really having a bad day. Depressed. Hopeless. Help me. What would you do?! Weigh in at the OTI Social Network’s Discussion Forum! http://onlinetherapyinstitute.ning.com/forum/ topics/coaches-and-therapists-ethical

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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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An Ethical Fram the Use of T in

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mework for Technology n Coaching

Introduction

As the Institute expands its services to encompass all types of helping professions, one of our main priorities was to address online provision by the coaching profession. With so many

By Lyle Labardee,

differing strands of coaching available,

DeeAnna Merz Nagel

we sought the additional expertise of

and Kate Anthony

Lyle Labardee, of LifeOptions Group Inc, to adapt and expand our original ethical framework for mental health into an ethical framework for the use of technology in coaching. The Framework that follows is designed to apply to all coaches, whether they use technology simply for appointment settings, enhance their

face-to-face

telephone

coaching practice with other elements of technological interventions, or conduct a coaching relationship entirely by online methods.

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The Framework A competent coach 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. Coaches have a sufficient understanding of technology. Technology basics are required for coaches who choose to deliver coaching services via technology. Coaches will possess a basic understanding of technology as the technology relates to delivery of services • Encryption: Coaches understand how to access encrypted services to store records and deliver communication. Records storage can be hosted on a secure server with a thirdparty, stored on the coach’s hard drive utilizing encrypted folders or stored on an external drive that is safely stored. • Backup Systems: Records and data that are stored on the coach’s hard drive are backed up either to an

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external drive or remotely via the Internet. • Password Protection: Coaches take further steps to ensure confidentiality of coaching communication and other materials by password protecting the computer, drives and stored files or communication websites. • Firewalls: Coaches utilize firewall protection externally or through web-based programs. • Virus Protection: Coaches protect work computers from

viruses that can be received from or transmitted to others, including clients. • Hardware: Coaches understand the basic running platform of the work computer and know whether or not a client’s hardware/ platform is compatible with any communication programs the coach uses. • Software: Coaches know how to download and operate software and assist clients with the same when necessary to the delivery of services.

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• Third-party services: Coaches utilize third-party services that offer an address and phone number so that contact is possible via means other than email. This offers a modicum of trust in the third-party utilized for such services as backup, storage, virus protection and communication. Coaches work within their Scope of Practice. Scope of Practice indicates the specific area to which a coach may practice. Coaches also follow local and regional laws and codes of ethics as applicable. • Coaches will accurately identify their coaching qualifications, expertise, experience, certifications and credentials. • Coaches maintain a reasonable level of awareness of current best business practices and professional information in their fields of activity, and undertake ongoing efforts to maintain competence in the skills they use. • Coaches understand and clearly communicate

the distinction between coaching, consulting, psychotherapy and other support professionals. • Coaches understand and adhere to responsibility to refer clients to other support professionals when needed. • Coaches will encourage their clients or sponsors to make a change if the coach believes the client or sponsor would be better served by another coach or by another resource. • Coaches do not attempt to maintain simultaneous counseling and coaching relationships with client even when properly qualified as a coach and licensed in another profession such as counseling. • Coaches adhere to professional codes of conduct as published by internationally recognized professional coaching organizations. • Coaches will recognize and honor the efforts and contributions of others and not misrepresent them as their own. Coaches understand that violating this standard may leave them

subject to legal remedy by a third party • Coaches respect the specific laws of a potential client’s geographic location. While coaching may not be a regulated field where the coach is located, coaching may be (or become) regulated in other parts of the world. Coaches seek out training, knowledge and supervision. Training, knowledge and supervision regarding coaching and technology are paramount to delivering a standard of care that is considered “best practice” within one’s geographic region and within a global context. Coaches are encouraged to demonstrate proficiency and competency through formal specialist training for online work, books, peer-reviewed literature and popular media. Coach and/or peer supervision and support are mandated for coaches who cannot practice independently within a geographic region and is highly recommended for all coaches. Coaches keep themselves informed of new technologies, practices, legal requirements and standards as are relevant to the coaching T I L T MAGAZ I N E MARCH 2 0 1 1

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profession. • Example Topics of study related to Training, Knowledge and Supervision include but are not limited to: »» Online Coaching »» Online Coaching Supervision »» Online Peer Supervision »» Avatar Coaching »» Cybercoaching »» Text-based Coaching »» Telehealth »» Behavioral Telehealth »» Social Media »» Mixed Reality »» Online Relationships »» Second Life »» Online Peer Support »» SMS Text Messaging »» Virtual Worlds »» Virtual Reality »» Coaching and Technology • Formal Training: Coaches seek out sufficient formal training whenever possible through college, university, accredited coaching institutes or private settings. Formal training is displayed on the coach’s website. • Informal Training: Coaches complete continuing

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education and professional development and conferences, conventions and workshops. • Books: Coaches read professional books written by the general public and professionals credentialed in their field. • Peer-reviewed Literature: Coaches read peer-reviewed literature that includes the latest theories and research. • Popular Media: Coaches are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of coaching and technology on the popular culture. • Coach/Peer Supervision: Supervision is sought by all coaches who deliver services via technology. Coach and peer supervision is delivered either face-to-face or via encrypted methods. Coaches display pertinent and necessary information on websites. Websites provide access to information for the general

public, potential clients, clients and other professionals. • Crisis Intervention Information: People may surf the Internet seeking immediate help and may misunderstand the kinds of services a coach provides. Coaches provide clear explanation as to the limitations of services provided and display crisis intervention information on the home page. Offering global resources such as Befriender’s International or The Samaritans is the best course of action. • Coach Contact Information: Coaches offer contact information that includes email, postal address and a telephone or VOIP number. While it is not recommended that postal addresses reflect the coach’s home location, clients should have a postal address for formal correspondence related to redress, subpoenas or other mailings requiring a signature of receipt. Coaches 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 inquiries.

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â&#x20AC;˘ Coach Education: Coaches list degrees, licenses and/ or certifications. Wherever possible, links supporting independent verification of certification and, or membership in a related professional organization should be provided. Coaches 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 coaching and technology. â&#x20AC;˘ Terms of Use and Privacy Policy: The Terms of Use agreement and Privacy Policy documents are posted by the provider of the website and appear on websites used by the coach to promote and/ or deliver coaching services. These documents outline what the user of the website and associated services may expect with respect to the availability of the website

and related web services, and how private information is collected, stored and protected. Coaches using a web-based coaching platform (website) or web service provided by a third party provider will ensure that the Privacy Policy conforms to the privacy practices standards that the coach is held to by the governing agencies operating within the geographic region in which coaching services are provided.

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personal information transmitted through the website is protected.

»» The Terms of Use agreement often appears in the footer of a website’s homepage and outlines the conditions under which the provider of the website makes the site, not professional coaching services, available. The agreement is between the provider of the website (which may not be the coach) and the users of the website. It specifies what is expected with respect to the web site provider’s provision of website availability and security, and the web site user’s use of the web site with respect to adherence to site policies regarding 30

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posting information and use of copyrighted or trademarked information and links to third party websites. It also often incudes a warranty and disclaimer regarding availability of the website. Information concerning the nature of the professional coaching services provided by the coach to the client should be provided in a separate Informed Consent document which is then executed as a contract for coaching services. In addition, the Terms of Use agreement should reference an associated, yet separate, Privacy Policy to specify how

»» The Privacy Policy often appears in the footer of a website’s homepage and outlines how the provider of the website and, the coach who may be using the website or web services to communicate with the client, collects and protects personal information. It defines what type of personal information is collected, how it is collected, what is done with the information, how it is protected (encrypted), how it is managed by all of those engaged by the provider of the website service, what the user of the website service can do to protect personal information and who to contact regarding concerns about personal information. It also addresses, if applicable, how payments are securely processed and it should conform to the widely accepted standards that are in place within the geographic area where services are provided

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such as the Fair Information Practice Principles in the US and the Data Protection Act in the UK. »» Coaches must also be cognizant of laws regulating professional practices within their geographic jurisdiction, and in particular, the standards and practices governing how a record is maintained and what privacy and security rules may apply. In some instances coaches may also be a health care provider by way of employment, education, certification and/or licensure. A circumstance may arise in which a government regulated license or certification may supersede the role of coach, in effect, rendering the coach a health care provider. If that circumstance arises, the coach may need to follow pertinent laws and practice standards governing the use and disclosure of protected health information such as those applying to US health care providers under the Health

Insurance Portability and Accountability Act (HIPAA) provisions as outlined by the Health Information Technology for Economic and Clinic l Health (HITECH) act. • Informed Consent: The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information concerning the nature of the coaching services proposed and how information is managed is accessible via an Informed Consent document posted on the coach’s website. The information in the Informed Consent includes: »» A clear description of the coaching that will be provided to the client. »» How web-enabled and associated telephonic and face-to-face coaching services, as available, will be provided and supported. »» An overview of the coach’s professional qualifications, training and experience. »» A review of the pros and cons of online coaching including such

disadvantages as lack of visual and auditory cues and the limitations of confidentiality via technology, and advantages that include easy scheduling, time management and the absence of transportation costs. »» How confidentiality is maintained and personal information is protected: Clear explanation is provided regarded the use and limits of technology with respect to secure (encrypted) and unsecure (unencrypted) communications such as text/mobile messaging. Guidance is provided on which type of technology should be used for secure communications and which may be used for administrative tasks such as scheduling. »» The Informed Consent will also reference the aforementioned Privacy Policy outlining the standards and procedures that will be adhered to regarding data protection, storage, management, and transmission of protected health information. A T I L T MAGAZ I N E MARCH 2 0 1 1

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statement identifying the coach as the owner of the coaching record including all transcripts, notes and emails, unless otherwise specified through law in the coach’s geographic location, will also be provided. The client is informed that posting direct information about the coach or verbatim information from sessions is prohibited. • How to proceed during a technology breakdown: The client is informed about how to proceed if a technology breakdown occurs during a session, e.g. “If we disconnect, try to reconnect within 10 minutes. If reconnection is not possible, email or call to reschedule an appointment.” • Who to contact in case of an emergency: Coaches offer specific information about who to contact in case of an emergency and set specific rules about emergency emails that the coach may not be privy to e.g. (suicidal emails in the middle of the night, threatening posts on a support forum). Coaches research local resources within the client’s geographic

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area as emergency backup resources. • How cultural specifics may impact treatment: Coaches discuss varying time zones, cultural differences and language barriers that may impact the delivery of services. Coaches should also ensure at or prior to the start of coaching, that the client’s expectations of the service being offered (such as the meaning of the term ‘coaching’ etc.) is sufficiently close to their own understanding and should take into account that different cultures around the world can have very different understandings of these matters. • How professionalism will be maintained: Coaches discuss with clients the expected boundaries and expectations about forming relationships online. Coaches 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 to preserve the integrity of the coaching relationship and protect confidentiality. If the client

has not been formally informed of these boundaries prior to the coach receiving the request, the coach will ignore the request via the social media site and explain why in subsequent interaction with the client. • Coaches will seek to avoid conflicts of interest and potential conflicts of interest and, if a conflict arises, openly disclose any such conflicts. Coaches will offer to remove themselves when such a conflict arises. Coaches conduct an initial interview and evaluate the client’s ability to effectively engage in technologyenabled coaching. The initial interview and intake process begins with the potential client’s first contact. The coach implements informal measures for screening a client’s suitability for delivery of coaching services via technology. • Client’s Technology Skills: Coaches screen potential client’s use of technology through questions at the outset. Questions include but are not limited to an inquiry about the client’s experience

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with online culture e.g. email, • Client’s Potential to Benefit chat rooms, forums, social from Coaching: Coaches refer networks, instant messaging, clients presenting with acute online purchasing, mobile emotional distress and, or texting, VOIP or telephones. other symptoms of significant Coaches ensure that the mental distress or disorder client’s platform is compatible to appropriate mental health with the varying programs and services. platforms the coach may utilize • Coaches enter into a during the course of coaching. contractual agreement • Client’s Language Skills: with the client to provide Coaches screen for language coaching services. Coaches skills from the initial contact will carefully review the through the first few Informed Consent with the exchanges. Assessing for coaching client and will strive language barriers, reading to ensure that, prior to, or and comprehension skills as at, the initial meeting, their well as cultural differences is coaching client and sponsors part of the screening process. understand the nature of Text-based coaching may coaching, the nature and limits also involve screening for of confidentiality, financial keyboarding proficiency. arrangements, and any

ABOUT THE AUTHORS Lyle Labardee is a distance counseling credentialed, Licensed Professional Counselor specializing in web-enabled coaching. He is co-founder and CEO of LifeOptions Group, Inc. 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.

other terms of the coaching agreement including how coaching information will be exchanged among coach, client, and sponsor (the person contacting for and paying for coaching.) The coach or coaching organization will have the client sign the Informed Consent, the coaching contract, and thereby enter into an agreement for coaching. CONCLUSION Members of the coaching profession – including those who have chosen a career as therapist-to-coach, as many of our members have done – recognise a need for such a framework that is adaptable to their particular strain of coaching. There is a fascinating – and assuredly on-going discussion to be had about how technology has a place within the coaching profession and the how it may best be utilised ethically. As with other Frameworks, we hope this provides a useful start point for discussion for all members of the helping professions to incorporate extra care in delivering services. n

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REEL CULTURE

Jean-Anne Sutherland

The Loss of Jill Clayburgh Feminist Ideals in Film

In November of 2010, Jill Clayburgh died from a 21year battle with leukemia, and the movie industry lost a significant presence. In the flood of obituaries, each noted that Clayburgh will be remembered for having portrayed strong, independent women; having come of age during the 1960’s feminist revolution, she brought that spirit of strength and empowerment into her performances. Clayburgh is perhaps best known for her role as Erica in 1978’s An Unmarried Woman. When I saw that film, in 1978, I would have been about 16 years old - yet I have recalled vivid memories of it over the years (I can’t say that about the zillion other movies I saw in my youth). I can still see (and feel) vividly the scene as she walks down the street, her husband having just told her that he is in love with another woman. In the bustle of sidewalk traffic, she stops, succumbs to emotion, collapses into a light post and throws up. I will never forget the ending, when she tells the adorable Alan Bates that she is not going with him. Rather, she decides that alone is okay and walks home, through the streets of New York, carrying that massive painting of his. Watching it again recently, it occurred to me that it was perhaps the first image I’d seen of a woman who, once broken, does not find resolution via revenge or another man. Rather, she finds her own strength. She doesn’t leave Alan Bates. She simply refuses to follow his dream at the expense of her own.

The prevalence of of powerful women characters in film has fluctuated throughout film history. Some have argued that strong women protagonists are “out” due to lack of interest or, more specifically, sales – after all, the major movie-going audience is young men (Hornaday, 2009). In previous works, I’ve argued that there are three types of powerful women in film: • those who wield power over others; • those who have the power to enact some kind of personal change; • those who embody the collective power that happens when women work together for social change. The first is not what feminists had in mind at all – that women would acquire the power that men have long held and use it to oppress others. The second is better as it shows us how individual women break free of societal expectations or abuse. The third, however, is the more significant and political as it portrays actual change – not just for one woman, but for women. (I think someone in the 1970’s said “The personal is political”) Mostly we see the first version: “power-over.” Meryl Streep, in The Devil Wears Prada, is powerful, yes, but she uses it to terrify and demean others while lacking the emotive skills needed to maintain relationships (hmm, rather like Michael Douglas in Wall Street). Or, we are given Lara Croft, the powerful fighting machine who is sexualized to the point of silliness. Neither are particularly threatening to patriarchal structures, feminists would argue. T I L T MAGAZ I N E MARCH 2 0 1 1

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More and more we see examples of the second: when a woman finally leaves her abuser (The Waitress); shakes up a rigid community (Chocolat); or, discovers her lost sexual self (Stella Gets her Groove Back). This image of personal “power-to” is better than the first. It gets at social change, albeit among individual women. We are given fewer examples of the third kind of power: power-with. We saw it in North Country when Josie’s sexual harassment lawsuit (the first against an employer) would not succeed until the other women (and men) stand together. In The First Wives Club, three jilted women decide that revenge against their husbands is no less reprehensible than the men’s behavior and channel resources into the formation of a non-profit organization for aiding abused women. In these films we see real social change. THAT, I suspect is what the feminists of the 1970’s had in mind.

As Jill Clayburgh walks home at the end of An Unmarried Woman, she has discovered her personal power. At the same time, that image spoke to a generation of women working together to make the personal political. That is the representation of power that I would like my 12-year old daughter to see: women using power to better their lives and the lives of others. Hopefully this image is not fully “out.”

BUY NOW

Jean-Anne Sutherland, Ph.D. is assistant professor of sociology at University of North Carolina Wilmington, USA with one of her research focuses being sociology through film.

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

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Take Care in Online Supervision/ Consultation Groups to Avoid Liability One of the most valuable experiences of my university counseling center predoctoral internship was our group supervision sessions. The therapists-in-training would sit in a large room with the senior clinicians, all arranged in a big circle. One-by-one we would each discuss a case we'd been working on, asking questions and receiving feedback and guidance. Not only was this a great way to learn and share--it was also an opportunity to feel supported and accepted by one's peers - "You're doing the right thing". Today, some online mental health professionals choose to engage in Internet-based group supervision or peer consultation groups, and this month I want to address some legal considerations for those types of activities. We need not go into the specific risks of liability for online supervision, which are similar to risks associated with online therapy generally and which I've discussed at length elsewhere. Rather, mainly I want to remind online supervision group participants that there is such thing as supervisor liability and offer some ideas for how to manage your risk, whether you're giving or receiving supervision for online clinical work. This is not meant to be a complete discussion, nor does it come with any guarantees, but my hope is that it will raise awareness and generate some new best practices for the benefit of professionals and clients alike.

LEGAL BRIEFS

Jason S. Z ack

Supervisory Negligence and Supervisor Liability An attorney hired to sue a therapist for malpractice might be pleased to learn that therapist was being supervised. On one hand supervision might weigh in favor of a decision that the therapist was acting prudently and consulted before acting, but it could also provide a source of additional (and potentially deeper) pockets to look for compensation. In that case, the plaintiff’s attorney would consider whether the supervisor could be held vicariously liable for the supervisee’s actions, or directly liable for the supervisor’s own failure in supervision. If there is a formal supervisory relationship, the supervisor might be held liable for the supervisee’s actions, solely based on the relationship, under the doctrine of respondeat superior. Consider this commentary from a relatively recent New York state court opinion: In relation to supervision of a licensed master social worker or a student, extern or intern in a mental health discipline who is providing clinical services under supervision, it means that the patients or clients being served by the supervisee are considered patients or clients of the supervisor, not of the supervisee, that the supervisor is

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personally professionally responsible and accountable for the evaluation, care and treatment of these patients or clients, that the supervisee is acting under the umbrella of the supervisor's license, and that the supervisor is personally professionally responsible, accountable and liable under the doctrine of respondeat superior for the professional conduct, misconduct, malpractice and actions of or the failures to act by the supervisee in relation to the patients or clients with regard to whose evaluation, care and treatment he or she is the supervisor. People v. R.R., 2005 NY Slip Op 25561, 15 n.25 (N.Y. Sup. Ct. 2005). There may be additional considerations such as whether the supervisor was in a position to know what the supervisee was doing, etc. Even if not held vicariously liable for the supervisee’s actions, a supervisor can be held directly liable for his or her own negligent supervision. Negligence requires a finding of (1) duty; (2) breach; (3) causation; and (4) damages. An informal supervisor or consultant could take on a duty simply by getting involved with the case, even if there is no formal supervisory or clienttherapist relationship. Once that happens, it is just a question of whether the client’s injuries were caused by the supervisor/consultant’s breach of that duty (actions or inactions).

In an online setting, supervision and consultation can be perilous for the same reasons as online counseling itself. First, the remote nature of the interaction can prevent a supervisor from having enough information to exercise good judgment in making recommendations; second, the relative anonymity and unfamiliarity with the parties involved (both therapist and client) makes it difficult to know enough about the counselor’s skills or the seriousness of the client’s situation. Third, the nature of online communication can make it challenging to offer guidance that might be misinterpreted from a tone or subtext standpoint. Finally, the disinhibition effect of online communication could lead peer supervisors to say things or make recommendations that they would otherwise not say in person. Online forums lend themselves to quick comments meant to be taken lightly but which could be misinterpreted as an actual recommendation. And of course—it’s all “on the record”. A final point is that certain professional ethics codes do require intervention in situations where one has knowledge of another professional’s negligence. See, e.g., § 1.05 of the APA Ethical Code (“Reporting Ethical Violations”). As I’ve written elsewhere, a violation of an ethical code can be sufficient to establish a breach of duty, especially where the ethical code has been incorporated into the state’s laws regulating that profession. Suffice it to say that in a group setting, not only would the therapist be a defendant, but each of the peer supervisors could be potential targets as well. Moreover, depending on the nature of the claims, the group host might also find herself a potential defendant if she were running a peer supervision forum in a manner that could be deemed negligent (e.g., security lapses, soliciting unqualified participants, etc.).Riskment Strategies

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Risk Management Strategies So how do you help protect yourself if you want to tap into the knowledge base of your peers? Here are some thoughts: - Take care with disclosure. Be careful not to forget how little control you have over what you write after you write it, and recognize that your comments are there forever. Even if you have the power to delete a post from a forum, someone might have printed or forwarded it or it could be archived. Likewise, if a group participant seems to be sharing too much, you might consider advising them to scale it back. - Watch what you advise. Be very clear on what is or is not advice, thoughts, brainstorming or whatever. The more it sounds like you are advising your peer “supervisees” on what to do, the harder it will be to argue later that you didn’t have some kind of duty or awareness of potential harm. - Wear protection. If you plan to supervise others, check to see if your professional liability insurance includes supervision coverage. - Set boundaries. Establish a written set of “terms & conditions” for your supervisory/consultation group to which all participants must agree before participation. Possible provisions might include: agreeing not to quote, print or forward any posts by other participants; clarifying that participants are not employees of one another; disclaiming any responsibility for other participants’ actions (for what it’s worth). Finally, set forth some clear rules for the discussion. What’s off limits? What happens in case of a dispute? Note you shouldn’t need to worry about getting people to fax in a signed agreement or anything. Click-throughs and email acknowledgements are generally sufficient and what is most important is that you keep a record.

- Hands on / Hands off. If you do have a formal supervisory relationship, you will be likely be held accountable for any negligence of your supervisee. In that situation it is important to monitor and maintain control of the case as much as possible. This might be difficult in an online supervision context as out-ofsight can mean out-of-mind. Don’t be deceived by the distance. On the other hand, absent a formal supervisory relationship, the wiser course of action might be to have less control and involvement with the case, to avoid acquiring a duty of care where there otherwise would not be one.

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

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TILT – Therapeutic Innovations in Light of Technology

Ly l e L a b a r d e e

TECHNOLOGY ENHANCED D Welcome to the first in what will be a regular TILT column on Technology Enhanced Coaching (TEC). Now some of you may already be thinking “TEC” is an oxymoron as surely technology, beyond the use of a telephone, is apt to only interfere with the coach’s ability to establish and maintain “presence” with the client. For those who may be unfamiliar with the term as it relates to coaching, “presence” refers to the coach’s ability to be “fully present” to the client; in other words, alert, keenly focused on the client and actively listening in every sense of the term. In fact this is so critical to coaching that the International Coaching Federation (ICF) holds that coaching by definition must be done face-toface or over-the-phone, otherwise it is simply not coaching. I agree. While it may be surprising to hear this coming from one who has invested considerable time and resources in the development of a web application to support coaching, I have come to appreciate that coaching is unique among the helping relationships with respect to the relative degree of importance it places on “presence”. While essential in all professional helping relationships, “presence” is of utmost importance in the coaching relationship because coaching is based, not on a “diagnose and treat” medical model, but on the premise that the client does

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not present with a need to be assessed, analyzed or directed; rather the client is viewed as complete and fully capable of resolving, discovering and directing their own actions successfully. To the extent the coach supports such discovery by being fully present to the client and artfully facilitating the client’s self-directed journey, the client will begin to actualize their potential to identify, express and achieve all that is within him or herself. Thus, I make a distinction here between “Technology Enhanced Coaching” and “online coaching”. While the latter suggests that coaching might be done entirely and only via asynchronous email communication (not something I personally would recommend), the former serves to enhance coaching grounded in traditional face-to-face or voice-to-voice interaction between the client and coach. To take this distinction a step further, I would suggest that an “online coach” is one who uses TEC to support and enhance, not replace the traditional coaching relationship. In the same way that we are beginning with the importance of“presence”we’ll also be

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D COACHING looking at TEC as a set of resources for supporting and enhancing core coaching competencies as outlined by, but not limited to, those published by the International Coaching Federation: 1. Meeting Ethical Guidelines and Professional Standards 2. Establishing the Coaching Agreement 3. Establishing Trust and Intimacy with the Client 4. Coaching Presence 5. Active Listening 6. Powerful Questioning 7. Direct Communication 8. Creating Awareness 9. Designing Actions 10. Planning and Goal Setting 11. Managing Progress and Accountability In summary, TEC should serve to enhance and support the established practices and standards of coaching, not re-define them. In addition to establishing the importance of TEC as a set of resources for reinforcing coaching’s

core competencies, I’ll also present, in this column, examples of TEC “tools” that serve to reinforce these core competencies. Examples of TEC tools likely to be featured include video/ chat conferencing solutions, private messaging solutions, and “widgets” that support interactive web-based functionality like “goal builders”, private journals and web based assessments. Lastly, I’ll also be featuring examples of web applications or “platforms” used to support the coaching relationship. These coaching web platforms typically offer a suite of features and functionality supporting communications such as private messaging, chat and video conferencing along with a number of other embedded widgets and resources to support the coachclient relationship and the client’s ability to work independently. I’d love to hear from you. If you know of a great TEC tool or web application that serves to enhance the core coaching competencies let the editors know, I may showcase it in the next issue. Lyle Labardee, LPC, DCC, is a distance counseling credentialed, Licensed Professional Counselor specializing in web-enabled coaching. He is co-founder and CEO of LifeOptions Group, Inc., and is based in Michigan, USA.

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

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BY Casey Truffo

From Therapist to Coach G

ina Hiatt, PhD, had a successful and full private psychotherapy practice outside Washington, D.C. for 25 years. She was wellknown in the area and had solid referrals sources sending her a steady stream of new clients. "I was seeing many people per week.” Gina says. “There came a time when I just got burned out. There were days I didn't feel like going into work. Then I heard about coaching and it sounded perfect for me. I wanted to travel more. I had visions of me talking to people on the phone from a balcony in Italy sipping cappuccino." Hiatt was also fascinated with academia. "I loved talking to academics. They are so intelligent and motivated." The Internet intrigued her as well. In 2003, she began helping graduate students with "dissertation coaching" - helping them move through writer's block to finish their dissertation. With a strong niche market and after “getting a PhD in Internet marketing,” as Hiatt jokes, her business grew. Today she has expanded her thriving coaching business into 'The Academic Writing Club.' This online group coaching "club" (membership site) is a support system with a combination of accountability tools and coaching to teach and support the process of academic writing. Her program attracts hundreds of graduate students, professors and researchers.

With a sense of both excitement and contentment, Hiatt reports, "I love this work. I get to help and support amazing people, work fewer hours and make more money than I ever did as a therapist." Hiatt eagerly and successfully moved from therapist with a private practice to running a coaching business. I don’t hear many stories like hers. I began to wonder why.

What’s the Problem with Coaching? When the field of Coaching emerged about a dozen years ago it seemed like a fantastic way for therapists to expand and enrich their practices. After all, therapists were already trained in many coaching skill sets. Coaching offered the promise of working with higher-functioning individuals and help them move forward on positive issues. Combining therapy and coaching seemed like a natural fit. The promise was bright. No pathologizing. No DSM diagnosis. In addition, the work environment was so flexible; it could be done at home, over the phone. This offered the potential for reducing travel time, working remotely (from the ski hill or the beach) and shrinking (or even eliminating) overhead expenses if

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a therapist decided to give up the ‘bricks and mortar’ office entirely. By eliminating these typical logistical barriers of geographic boundaries, the field of coaching offered the opportunity to reach and help more people around the world. A client could come from around the corner as easily as from the other side of the world. The potential for earning a great living looked good too. Like many therapists years ago, when I first heard about the ‘new’ field of personal coaching, I got excited. The more I learned about coaching the more I wanted to know. A coach was described as a type of personal mentor. A person a client could rely upon to help set long term goals along with the short term ones necessary to achieve them faster and easier. I pictured a person that would help keep their client on track with the progress of those aspirations.

This fresh, objective set of eyes would offer a knowledgeable perspective to help identify and call a client out when they were ‘getting in their own way’ and interfering with their own personal progress. The beauty of it was that all of this support was available with a simple phone call or email. As a therapist, I knew I had many of skills to offer coaching. I dreamed of higher functioning clients who wanted me (and paid me well) to help them get out of their own way.

From Therapist to Coach Considering all that, I decided to become a life coach. I went to business networking meetings to share my love of this new field and all its benefits. I told my networking colleagues that, while I was still a therapist, I was now also a “coach” and could “help you get from where you are now to where you want to be.” You can imagine the eye rolls. No one wanted to pay hefty coaching fees for “getting from one place to another.” I sounded like a Fed-Ex ad. So I adapted. I revised my marketing message to say, “I help you meet your goals quicker and faster than you could on your own...” (…for the mere price of a few hundred dollars a month). I was enthusiastic and confident. I prepared for the flood of emails and calls and planned for the onslaught of new client sign-ups. After nearly of year after opening my “life coaching” business, the number of coaching clients swelled to – one. Not exactly what I had hoped for. On the other hand, my therapy practice was thriving. Why? Unlike coaching, I found I never had to explain the need for therapy to a potential client. Trying to sell a process – even a powerful one like coaching – is simply not easy.

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So why isn’t there now a horde of therapists-turnedcoaches with full caseloads working around the world? Why haven’t more therapists either added coaching to their tool kit or replaced their therapy practice altogether? Why haven’t more therapists who disliked the medical model of therapy left the field to become full time coaches? The simple fact is that, while some therapists are making a great living offering coaching services, the majority are not. Many have tried to offer coaching on their menu of services (or even jumped in with both feet and started a coaching company) but haven’t been successful. Why hasn’t the coaching-therapy model taken off even though it seems like a natural fit? There are a few possibilities that hold therapists back from donning the coaching cap:

1 Therapy has a history and is a long standing institution. Coaching is considered by some as lacking credibility -- just a bunch of “positive thinking.” Almost everyone born somewhere in the last 60 years has heard of psychotherapy. While the field has evolved significantly over time, it is still understood by many in our culture as a way to resolve emotional, relational or mental problems and even existential angst. The discipline of coaching simply doesn’t have that reputation. For many, the value one receives from coaching isn’t clear. It isn’t only the general population that is confused about the value of hiring a coach. Some therapists are quite outspoken about their disrespect for coaching.

On my blog there has been quite a discussion about coaching versus therapy. Some psychotherapists have expressed great concern for potential coaching clients due to the lack of licensing requirements for coaches. Anyone can legally hang out a “shingle” and call themselves a coach. The fact that anyone could offer coaching services without training or licensure does cause one to pause. Coaching currently has no legal regulating boards which, although attractive to some, cause great concern with other clinicians. Other therapists question the way in which coaches are marketing for clients. Much of it is done over the Internet by way of websites that offer big promises. I’ve been told, “Those coaching websites look like late-night infomercials of the ‘get rich quick’ variety. They seem so ‘in your face’ with Internet selfpromotion. It is unseemly.” Then there is the question of the efficacy of coaching. After years of outcome research, we know “therapy works.” We cannot say that for coaching. Until there is equal research done, the efficacy of coaching will probably be in question. This seeming lack of a ‘credibility factor’ can turn off many therapists from even considering entering the field.

2 Therapy clients are easier to acquire than coaching clients. Traditionally it’s been easier to acquire new therapy clients than coaching clients. This is because therapy, as mentioned, is a proven, time-honored, respected method of dealing with relational and emotional issues. Other professionals, clergy, schools, and other healthcare workers honor the profession and refer clients to us.

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Coaching seems, at least on the surface, to be a process in search of a problem. No one wakes up at 3 a.m. saying, “I need to find a coach.” Successful coaches in private practice are predominately the ones who specialize in a focused, narrow niche. While this is becoming increasingly important for therapists, it has always been a make-it-or-break-issue for most coaches. It seems reasonable that if therapy clients are easier to find than coaching clients, there would be little long-term motivation for therapists to leap into the area of coaching. Any movement from one area to the other tends to be pursued conservatively.

3 Coaches need a well-defined niche to be successful. A coaching practice needs a niche and a message. Successful business coach, and my personal mentor Andrea Lee says the key to building a great coaching practice is to “have something frigging amazing to say” to your niche market. I’ve heard of one coach who works with “women who share custody with jerks.” Now that’s a niche! Many therapists are reluctant to be so bold and it would be seen by many as distasteful. While this boldness might be inspiring to coaching clients, being this provocative can feel counterintuitive to many therapists – and even considered inappropriate for many psychotherapy clients and practices. If people won’t buy a process (like Coaching), then what do they want? They want a solution to a problem. While this is also true for therapists, it is critically important for coaches. Financially successful coaches tend to market to a very narrow niche. These coaches have powerful messages and get those messages out through strong marketing campaigns. 46

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“When I started out as a coach I didn't have a niche nor did I want one. I lived in scarcity and didn't want to turn away any business. Once I defined my niche I was much happier. I knew where I could market my services instantly. I had 4 new clients within one week and I was quickly able to produce a newsletter because I had a defined subject matter to write about” says Sandra De Freitas, known as the Tech Coach. De Freitas continues, “When a coach has a niche it’s easy for others to send referrals to him or her. You wouldn't go to a general family doctor when you need hip replacement surgery. Coaches and Therapists with niches are known as specialists and experts. As a Tech Coach, I would hope that no one would want to hire me to be their divorce coach. I know nothing about divorces and I have no desire to coach someone on the subject matter.” Traditionally therapists have been reluctant to specialize in one particular niche. Therapists who attempt the transition from therapy to coaching without a strong niche usually fail. It took me some time and experience to figure this out. After my life coaching business failed, I augmented my therapy practice by coaching newly licensed clinicians to build their therapy practice. It was very exciting to see these new private practitioners attracting self-paying clients, as they were unable then to become providers on the insurance panels. My message was – and is – quite bold. You deserve to make a great living doing what you love. Marketing to a specific and narrow niche coupled with a bold and provocative message have been responsible for the success of Be A Wealthy Therapist and, more recently, the International Therapist Leadership Institute. Even though the message is uncomfortable to some, it has attracted and allowed us to serve over 30,000 therapists worldwide. Quite a difference from my life coaching caseload of one!

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You can have a full therapy practice (or could until the last few years) without much marketing. This is not the case with coaching and most therapists were trained to provide therapy, not to market their services. The nature of the typical therapist is client-centered and, until recently at least, therapists didn't need to focus on a business and marketing orientation.

Successful coaching requires a full-sized curiosity and ability in business, marketing and the Internet (both technically and strategically). The therapists-turned-coaches who are most successful are the ones who are as excited about building their business as they are about doing the work. It’s the difference between working on your business and working in your business. Coaches need to be adept at doing both to make it. It takes a desire to learn a very different set of skills than the “client work” requires. At first glance it may look like the “work” of therapy

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and coaching are the same – while the clients and their issues are different. As noted, making a great living as a coach is not easy. Successful coaches are interested and curious about marketing and how to leverage one’s time to help more people and make more money. Many therapists have told me they would love to be a coach but don’t want the burden of building a coaching business. One of the more unique characteristics financially successful coaches share is having business acumen. You MUST have a nuanced understanding of your market, your marketing strategy and the business savvy that you don’t need when you hang an ‘open for business’ shingle for a therapy practice. Jennifer Koretsky is a Senior Certified AD/HD Coach with a very successful coaching business called ADD Management Group. Koretsky shared her interest in business with me. “When I was growing up and when I was in college, I never thought I would be an entrepreneur. I wanted to get a PhD and become an English Professor. Ultimately, that didn't pan out and I worked in advertising and marketing for about 5 years before starting my business. I enjoyed the creative and strategic elements of my work, but I didn't fit into the corporate world. When I look back, I certainly had an entrepreneurial spirit as a kid. At 13, I created a marketing campaign for my babysitting services with flyers, phone calls, and networking referrals. I had no idea how out-of-the-ordinary that was for a 13 year old. I just wanted to make sure I got the jobs!” Koretsky was diagnosed with Attention Deficit/ Hyperactivity Disorder at age 25. “Having a defined niche has definitely been an integral part of building my business. However, I didn't start with the niche in mind. I started with my knowledge and experience and built my business around that. The niche found me, so to speak. Over time, I have been increasingly upfront about the types of people who will get the most out of working with me. While it seems

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counterintuitive, I have found that this actually creates more demand for my services” she comments.

5 They hadn’t considered hiring a business mentor. Most therapists will hire or attend supervision to improve their work with clients but those same therapists might not have even considered hiring a business coach to help them develop their practice. Having a business coach on your team can accelerate the learning involved in building a successful coaching practice. Gina Hiatt, Academic Writing Club, shares: “It was hard for me to switch into a business person. Part of my success was hiring a business coach - someone who understands business. My coach has helped me launch new programs and hire coaches to work in my business.” I agree. Hiring a business coach is a great part of my success as well. Andrea Lee has been my business coach for nearly 3 years. She has worked with Thomas Leonard (considered the father of modern day coaching) at CoachVille and has been instrumental in my success.

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She’s encouraged me to transition from a one-to-one coaching practice to a thriving coaching business. With her input, I’ve been able to push the envelope and offer products, services and virtual conferences that I’d never even dreamt of before I started. Hiring a mentor who has done what I want to do has minimized the learning curve and has helped me to serve more people around the world.

Is there more we can learn? Although the first blush of promise for therapists looking at coaching may have faded, there are still positive things we may gain from our cousins in coaching. The very thing that has attracted so much attention to coaching is something the field of therapy stands to learn a great deal from. It bears looking at: What is it about coaching that has made it successful with many? What are equivalent messages for therapists that would connect us to the public? The attractiveness of the career of coaching has generated attention due to the glamour of mobility and the ability to change lives. What stops us from expressing the work of therapy in attractive terms such as this? Will the arrival of online therapy and increasing therapy being done by phone put our work on par with coaching? Will we seize the advantage to make clear that clients the world-round can connect virtually with the perfect therapeutic support for them?

too radical to suggest that a therapist could fill that role? If we believe in therapy as much as we think we do, where are our heroes? Does anyone outside our field know of them? Can and should we have a Dr. Oz of therapy - someone who represents us well to the public? What else can we graft from the coaching world, to benefit ours? As I continue to see a select number of clients in both therapy and coaching modalities, it excites me to take the best of both worlds, always in search of the best for the client.

About the Author: Casey Truffo, MFT is an award-winning speaker and coach to therapists on five continents. She is the author of Be a Wealthy Therapist: Finally You Can Make a Living While Making a Difference. Founder of the International Therapist Leadership Institute (www.InTLI.com), her mission is to enrich the lives and careers of therapists worldwide. For tools, tips, videos, and her virtual conferences please visit www.INTLI. com, and www.BeAWealthyTherapist.com

We do, after all, need to continue to attract new blood to our profession and respond to the cultural changes that will demand more flexibility in service delivery. Personalities within coaching also affect its popularity. Tony Robbins and Cheryl Richardson attract millions with their charisma. If we want therapy to continue to attract new clients, would it be

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an Online Therapist

A Day in the Life of This really isn’t a job, it’s a lifestyle.

On the weekends I wake up at 8:00am, and switch on my computer. Blurry-eyed and half-asleep, I shuffle towards the kitchen for my Chai tea and Fruit for breakfast—sometimes this is pancakes. I sip my tea and look down at my sleepy town through my large lounge window; having a house with lots of space and a relaxing environment helps to keep me sane.

KYLIE COULTER

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Friday through till Monday is usually the busiest time for me with clients. Most of them are from America and I live in ‘The Land Down-Under’ (Australia), so the time differences are a little off – but this is a good thing. Clients tend to have more time on weekends and want sessions at night in U.S.A time, which is the morning in Australia. So after some necessary fuel, I head back to my computer and check my e-mails. I prioritise them and respond accordingly. My first client is usually at 9:00am. My hours are from 9:00am till 9:00pm. I don’t have children so I imagine that I have more freedom to allow these late working hours. After sending e-mails, I switch on my external hard drive and load up last week’s session notes including the established goals. It’s important to be well prepared for your sessions. I use paintbrush documents which I make up on the spot to use with clients. A visual aid helps to put difficult or complicated concepts into perspective for them. After reviewing the previous week’s session I plan my current one. I think about what I might say and how to make the most of the time we have together. I should mention that during the week I study psychology full-time. I could work online full-time if I wanted, but I’m aiming for a PhD specialising in online counselling, and this requires a lot of time and hard work.

conversation. It’s about quality over quantity and with more self-disclosures from clients, rapport tends to build rapidly. Within one session I usually know whether I can work with a client and if online therapy will suit them. So anyway, I finish the session with my client, and then afterwards I store the session on my external hard drive (which is usually locked away in my filing cabinet). I then go back through and take notes, see if I missed anything, think about how I could have improved on the session and then finish up. Did I mention I’m still in my pyjamas? It depends on how early I rose whether I’ve managed to make it to the shower before my first session – it is the weekend after all. Usually after the first session I go take a shower and come back to my computer and plan for my next client. Mostly I have 3 – 6 sessions a day. On Mondays I only have 1 -2 as I work at the university as a research assistant and I also run a free support group in Second Life, the virtual world. I live in a beautiful town in N.S.W, and for lunch sometimes I’ll sit in under a huge maple tree in my backyard or I’ll grab my bicycle and sail down the hill for lunch at a local café. I’ll take a book, usually within the genre of Fantasy-fiction or Sci-fi and

A lot of people question the efficacy of online therapy and how it can work without nonverbal communication. While less is said in text (typing is slower than talking), studies have shown that this is compensated for because the medium calls for more self-disclosures and clarification: more than is generally deemed appropriate in face-to-face

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relax while soaking up the sun. The problem with working online is you don’t get enough Vitamin D, your social life can suffer and don’t get me started on fitness. Taking care of yourself is important. Just because you’re working online doesn’t mean the work is easy. In fact, focusing closely on your clients is essential to effective online therapy. You should be very sensitive to the rhythm of their typing, their choice of words, word emphasis and you should always check that you understand them correctly --more so than in face-to-face. This is an exhausting process and the chance of burnout is very real. So, keep fit, eat healthy, get enough sun, socialise and you’ll avoid exhaustion. As technology develops so does the way we communicate; therefore, it seems only natural

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that online counselling is increasing in popularity. In the near future I think it will play a large role in how we provide mental health services to the world. It’s not for everyone, but I’m hoping that one day it will be.

About the authoR Kylie Jane Coulter is a qualified counsellor and is the founder of Lifechoices.net.au. She lives in Australia.

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

an Online

A Day in the Life of

My workdays all start the same: meditation, journaling, exercise, and a Starbuck's skim/no foam latte. But after that, it depends which day of the week we are talking about. In the last few years I have transitioned from a traditional psychodynamic psychotherapy practice to working as a money coach. So two days a week I commute from...

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e Coach

Lora Sasiela

...New Jersey to my office in

Manhattan and see a mix of psychotherapy and coaching clients. The other three days of the week I enjoy working from my home office with coaching clients, via phone and videoconferencing. This transition came after a bout of burnout. I had worked almost exclusively with eating disordered clients for over ten years, and my soul, depleted, was yearning for something new. Interestingly, it was my own 'money meltdown' that paved the way to my new career focus. Out of the ashes of my financial crisis arose a new specialty (money coaching) and a new business, Financially Smitten.com. Not only had I been experiencing burnt out, I was also feeling constricted by the therapy work. I found it limiting in so many ways:

geographically (being confined to work with people in the state in which I am licensed); interpersonally (needing to 'protect' the transference which precluded my being a 'real' person in the healing relationship); and financially (there were only so many hours a week I could see clients which created an income ceiling). So for me becoming a coach was all about LIBERATION. I love that I can support people all over the world and still get excited when a client from Australia or the UK shows up at my virtual door. I love feeling free to use my own experience to help inspire and educate my coaching clients. I love being able to channel my creativity into producing information products for sale on my website. I love not having to worry about an 'ethical dilemma' when I send my coaching clients a small welcome gift. But the transition, as most, has not always been smooth.

I spent a lot of time struggling to shake off my 'therapist' identity and persona. To step out of the 'blank screen' world of therapy-land into the more transparent world of coaching was not easy for me. I had not realized how accustomed I was to not permitting my personal self 'into the room.' I remember literally shaking when one of my business coaches informed me that I was doing a disservice by not sharing 'my story.' She said, "How are people going to think you are authentic, going to believe you can help them, want to work with you, if they don't know about you?" ("because all my therapy clients do?" I countered, silently to myself!). But this was a whole new world, and it wasn't until her admonishment that I took in the amount of trust my therapy clients needed to walk into my office and share their most private selves with me--without knowing a thing about me. I respected that leap of faith in a way I never had before. My post-Masters training was based on a traditional psychoanalyitc-psychodyamic

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

framework, and my professional community reflected this. There was an implicit and explicit devaluing of 'coaches' (which, to be honest, I conspired with, until I personally experienced the transformational power of working with one). So when I started to move in this career direction (and as a money coach no less--a topic most therapist are not wont to talk about), there were some painful reactions from colleagues I had to deal with. These were definitely some of the bumps in the road.

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However, I remain appreciative of the time and effort it took to develop my psychoanalytic expertise, and how this foundation now informs the work with my coaching clients. So although I may not be technically 'working in the transference,' I am primed to spot those dynamics and can easily leverage them into the coaching work. I love being able to use these powerful insights without the dependency and regression typical of a psychoanalytically informed treatment (and with coaching clients, a vacation is

just a vacation....not something that has to be "pre and post" processed). Obviously another big difference between therapy and coaching is that--as I like to say-- "you don't have a client's butt on your couch for five years." This means greater client turnover, which in turn means greater marketing efforts. Here again, I love the freedom and transparency of blogging, publishing an ezine, and interacting on social media sites. I have also recently been taken with information

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products and am in the process of producing a number of them. There is something very inviting about multiple streams of income! One of the potential hazards of maintaining a home-based coaching practice is the inherent isolation. This is one of the reasons I continue to work in my Manhattan office two days a week. I am blessed to be in an office building I lovingly refer to as 'healing central,' because the tenants are primarily healers of all types, from therapists, to acupuncturists, to rolfers, etc. It provides a wonderful sense of community, and after having rented there for fifteen years, it's unusual for me to ride up in the elevator with someone I don't know. It also makes setting up collegial lunch dates a snap!

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Lora Sasiela is a psychotherapist turned financial coach. She works from home in New Jersey and offers in-person sessions in her Manhattan office two days a week. Check out her website at FinanciallySmitten.com

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Cyber Supervision Anne Stokes

Does breaking confidentiality feel more difficult for the supervisee with online clients?

Anne says: So you’d like to look at the issue of disclosing/ breaking confidentiality........

This issue featured an online session with a supervisee, who works in a university counselling service, offering both online and face-to-face counselling. There appeared to be some differences between the two ways of working regarding the ease with which this was discussed with the client and possible levels of discomfort within the counsellor.

What would you like to get from the discussion?

Below is a part of the transcript of our conversation. Although the transcript largely stands on its own, some of the points we discussed are revisited at the end of the article.

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Sarah says: Clearer understanding of where the balance lies in what I disclose and what I don’t even when I’ve been given consent. Anne says: Is it different for you online from f2f? Sarah says: When I work f2f, I discuss the intricacies more directly because I can gauge the answer to each stage. Perhaps it is the difference from working synchronously to asynchronously Anne says: Can you say a bit more about that?

Sarah says: When it is synchronous, I can take it step by step and get a sense of when it becomes too much. I am comparing f2f synchronous with online asynchronous. I wonder when I am working asynchronously, if I am more cautious about not frightening a client off. Perhaps I ask something in more careful terms that might be broader rather than detailed. I have to make a judgement on what is understood by my client. That leaves space to get it wrong so it feels bigger to hold. Anne says: It feels bigger to hold - have you an image of that bigger thing? Sarah says: It feels like trying to hold a big ball that is bigger than me and I don't

A Discussion in Cybersupervision

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know which way it's going to roll. I recognise it might roll out of my hands and I wouldn’t have any control over that. Butso far I have managed to keep hold of it. I may have permission to disclose with a client but that client may be very vulnerable and at risk. Therefore I feel it is important to walk really cautiously and there are times I am scared to trust my instinct. Anne says: Is it OK to go back to the ball a moment? What would you like to do? Make the ball smaller and able to be held, or find a way of keeping hold of it the size it is? Or put it down? Or?........ Sarah says: It is a ball I have to balance in the air by placing my hands underneath it.

Anne says: It feels quite fragile, tenuous somehow holding it in the air? Sarah says: As I was writing about the ball originally I was imagining holding it in the air. It‘s quite tiring at times holding it there. I was wondering if it would be different if it was a f2f client. My sense was that I wouldn’t be holding the ball so high in the air and it would be held between me and the client. Confused now. Does this mean I take more responsibility for clients when I work online? Anne says: Might be! I was going to ask if you felt you can trust them less to tell you what they need? Or is it you that you perhaps trust less - the instinct again?

Sarah says: It's like having to believe the person is on the other end holding the ball as well. I can think of online clients where this feels the case very strongly. Anne says: That they are holding it too? Sarah says: Yes Anne says: So there is something different for when the issue of disclosure/ breaking confidentiality comes up. Sarah says: The other image I have is going into a field to try to catch a colt who is very scared. I have to be very calm, very steady and work hard to create trust. I guess when we are working online

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

there are things that client can ignore which when I am working f2f I can pick up and although they can refuse to answer, it is clearer.

about horses really, but imagine itâ&#x20AC;&#x2122;s more reassuring for them if the person trying to catch them is not only calm and steady but confident.

Anne says: Just thinking aloud here.....from my knowledge of you, working f2f, you would be saying to the client something like 'I feel unsure of your reaction... feels like you both do and don't want me to do this'. Somehow, online you don't quite ask/ explore in the same way?

Sarah says: Yes definitely confident. So what I am wondering is whether I only ask the essential things so that it is easier to give consent and so I don't frighten the client

Sarah says: Yes I would ask that f2f and have done that online about less serious things. I guess when it is a case where I am seriously worried about whether a client will be able to stay alive then I want the answers to disclosure to be yes. I would much rather have consent than have to do it without consent. Even when I have enough grounds to breach confidentiality, it is obviously therapeutically better doing so with client consent. Anne says: I'm thinking about the colt - I don't know

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Anne says: So just wondering if in some cases you might need to actually say 'It feels right for me to talk to X about this now. I'd like to talk with you about how you'd like me to do that and what it feels like when I say that'. Something confident and less tentative maybe?

person starts a chain event. If I disclose to one person, does that mean that they can disclose to another person? Do I have consent for that or do I have to keep going back for further consent? Also my understanding of disclosure is that I can disclose around the particular issue but not other extraneous details. That is clearer in some cases than others. Checking this out with the client feels more difficult online than f2f.

We are talking about the unusual, the client's ultimate safety?

Anne says: So it's not only 'if' you disclose but 'what' you do? That is a complex decision. May I clarify something? When you contract with clients, is the confidentiality between the counsellor and the client; the client and the counselling service; the client and other services or â&#x20AC;Ś.?

Sarah says: Yes we are talking about when a client is extremely suicidal and has made attempts in the past so that it is not unrealistic that this will happen again. What I realise is that when you work within an institution often disclosing to one

Sarah says: The contract is with counsellor and counselling service. So that does not include other parts of the university or the GP or any assessment team. How do I maintain a safe relationship with a client whilst believing that sharing information is in

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the client's best interest? It feels important to be careful and to disclose cautiously but at the same time I do want others to be aware of the very real risks to the client Anne says: This may not be helpful in this moment, but I am wondering whether it would be usefulto have more in the contract about disclosure - how it happens etc. Also doing some work with people to whom you might disclose, about what happens to info then etc. It sounds as if one of the difficulties is that, once the disclosure is made, you've lost control of the information and are not sure how trusting you can be of the system when you don't know what will happen to it? That makes you very wary of what it will feel like to the client? Sarah says: We’ve had various discussions about disclosure. It’s complex because it is difficult to be definitive and it is looked at case by case. It seems appropriate for the university to have as much information as outside organisations. I also think that

more openness might be in the client’s interest but it is doing it at the client's pace and not rushing. Sometimes information could be used by an organisation in ways that might not seem immediately helpful to a client, even if they are in the long term. If I don't disclose then our counselling relationship may be kept safer but the client may need more than just our counselling relationship. Anne says: Hmm... a question that comes to mind here is whether you can always do it at the client's pace. As a university counsellor, what does your employer expect? That you avoid the client killing himself by disclosing before he is ready, or that you wait for him to take his time and he kills himself in the meantime? I am

sorry to put it so crudely, but I think you may be in a different position to an independent counsellor who is not 'acting on behalf of’ an organisation. Are you getting what you wanted from this - your aim was to get some clearerunderstanding. Sarah says: I think I am in a different position and as a university counsellor I have to be far more proactive than a private practitioner. What does my employer expect? It doesn't seem right that one

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

part doesn't know the risks that another part does, when they will be making serious decisions about the client. But the dilemma is how much is okay. Part of me wants to be very open if I believe that will be in the client's long term interest but if I think that might be too much for the client, it is finding the right path and balance. I am getting what I need because talking it through helps me see the dilemma and the balancing act I have to do to walk the right path. I like my colt image particularly, that feels helpful. The other image of the ball gives me a sense of the difficulty of holding this at times. Anne says: This may be an ongoing discussion and the clarity may come in steps? What do you need now from me (if anything!)? Sarah says: I am clearer about the complexity and difficulty of the balance. I recognise Iâ&#x20AC;&#x2122;ve been scared of frightening off a client and maybe skirting round a

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bit as a result. Perhaps now I can be clearer. When I am not transparent, I feel that my hands are tied behind my back because I haven't been clear. Anne says: And you can't hold a ball or catch a colt with your hands tied behind you back! Sarah says: No I can't do much with my hands tied behind my back. So, I need to face the fear of being more upfront with online clients even at the risk of losing them. That feels more genuine. I think when I am being too

careful with a client I tie myself in knots and there must be some transference in this, in that the client feels fragile Anne says: I'm aware of time, Sarah, and you need to go soon. It feels to me as if in the last few minutes, you've come up for air and sound more confident in your ability to hold the client and disclose if necessary. What would help you face the fear? Sarah says: I have to trust that my client can hold his own ball some times. Biting the bullet.

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I think that what struck me most clearly when reading through our transcript later was the tension between ‘beneficence’ and ‘nonmaleficence’, and I wish I had thought of it at the time! Within what Sarah was saying was her very strong commitment to avoiding harm to the client, as well as a commitment to promoting the client’s well being. If she does the latter, she will almost certainly disclose. However, there is the fear within her that this has an outside chance of doing harm to the client, as she has little control of what other agencies, both within and without the university, may then decide to do. How is this different when working with online clients? After all, exactly the same could

be said about the dilemma when choosing to break confidentiality with a faceto-face client. As I reflected on Sarah, her clients and the organization, I worked with stones to clarify my thoughts. I noticed that even though both sets of clients were close to Sarah, the face-to-face clients were initially much nearer to the organization than the online clients. That led me to speculate whether Sarah and her face-to-face clients can work more easily together with the ramifications of disclosure in a way that may be less possible with online clients. When disclosure happens, the online client moves into a face-to-face relationship with e.g. the welfare team, members of the academic staff and the medical profession,

concerning their welfare. Sarah and her clients remain in a virtual relationship. So what impact does this have? Can the counsellor (Sarah in this case) support the client as closely as she might be able to support a face-to-face client in the same position? I am not sure that I have any concrete ideas or ‘words of wisdom’ about possible differences in disclosure, but I do know that our discussion brought the possibility firmly to the front of my mind. I am extremely grateful to Sarah for allowing me to use our work together here. Thoughts from readers would be appreciated! Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer, and Director of online training for counsellors ltd.

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

Ne wInnovations The Hype Cycle of Online Therapy Mark Goldenson, with invited commentary by John Grohol (CEO & Founder, PsychCentral.com) In 1995, during the emergence of the Internet, Gartner Research published a theory about the evolution of new technologies. They called it the hype cycle and it had five stages:

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Technology Trigger: A technology breakthrough happens. Prototypes spark publicity and early adopters. Often no usable products exist and commercial viability is unproven. Peak of Inflated Expectations: More publicity drives a few success stories, often accompanied by scores of failures. Some companies take action; many do not. Trough of Disillusionment: Interest wanes as experiments and implementations fail to deliver. Technology producers shake out or fail. Investments continue only if the surviving providers improve. Slope of Enlightenment: More benefits of the technology crystallize. Second- and third-generation products appear. More enterprises fund pilots; conservative companies remain cautious. Plateau of Productivity: Mainstream adoption starts to take off. Criteria for assessing products are more clearly defined. The technology’s benefits are widely accepted.

The hype cycle is just a theory and I don’t think it’s always true. However, it is still useful for estimating the risks and rewards of adopting a technology at any given time. I think therapists just starting to practice online are implicitly wondering: where in the hype cycle is online therapy? Distance therapy has been conducted for decades via phone, closed-circuit TV, and early incarnations of the Internet. From talking with quite a few of online therapy’s innovators, here is my rough sense of its cycle: Technology Trigger: 1969-1992. In 1969, on October 29th at 10:30pm, the first message was sent on a network between UCLA and Stanford Research Institute called ARPAnet (photo-documented here). Martha Ainsworth writes that in 1972, one of the first simulated online therapy sessions was conducted. The Internet was not yet publicly commercial so there were few real sessions. Peak of Inflated Expectations: 1992-2000. The commercial Internet surged in 1992. The number of registered domain names nearly doubled every year from

16,000 in 1992 to 27,000,000 in 2000. In 1995, Dr. John Grohol coined “e-therapy” and hundreds of e-clinics opened like HelpHorizons, Here2Listen, and MyTherapyNet. Internet connections were still mostly dialup, making videoconferencing infeasible, and research on online therapy was still quite limited. Trough of Disillusionment: 2000-2008. The dot-com bubble burst and many online therapy companies closed. Web 2.0 companies like Skype launched and the first CPT code for online therapy was issued in 2004, but without much reimbursement or Internet adoption among providers, its practice grew slowly. Slope of Enlightenment: 20082014?. Milestones have sparked the field: broadband access and webcams are mainstream - 80% of Internet users now search for health information online and over 20% have had a video chat. The Mental Health Parity Act passed and the stimulus package allocated over $25 billion for healthcare technology. Over a dozen telemental health CPT codes exist and major payers are starting to reimburse. LeT I L T MAGAZ I N E MARCH 2 0 1 1

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Ne wInnovations gal issues around licensure, privacy, and security are becoming clearer. A few telehealth companies like athenaHealth and American Well are earning eight-figure revenues. Online therapy is regularly covered in mainstream press and dozens of studies now show online therapy works.

It is still early, but now is when online therapy will gradually become a credible, useful technology. It is growing fastest not in the mainstream, but in niches like rural clinics, prisons, and military. Thousands of providers are now using the Internet to stay connected with patients.

I believe online therapy is in the Slope of Enlightenment.

Plateau of Productivity: 2014 to ...! Itâ&#x20AC;&#x2122;s hard to say when online

therapy will go mainstream, but I think these will be some of the enablers: wide reimbursement by public and private payers, popular adoption of videoconferencing by providers, clear legal guidelines, validation by industry groups like the APA, and clients sharing their success stories. Almost everyone I know in mental health believes this will happen; the question is only when.

Invited commentary from John Grohol: Mark Goldenson's article, "The Hype Cycle of Online Therapy", is an optimistic take on the field of online psychotherapy that seems to miss a core component of building a successful business -- demonstrating a clear market demand for your product or service. His opinion doesn't seem to coincide with my own decade-plus experience in this field.

and the online disinhibition effect. Asynchronous communication refers to two people not being online at the same time, while the disinhibition effect refers to the observation that people tend to more emotionally disinhibited in their online, written communications. The most practiced form of e-therapy today -- done via secure email -- uses both.

"Major payers are starting to reimburse." Indeed, there is an exception or two amongst the major health care insurance providers who may reimburse for e-therapy sessions. But that is the exception, not the rule today -- just as it has been for the past decade. And if e-therapy is not significantly less costly than face-toface, what is the benefit of it?

The benefits of e-therapy. There are a multitude of benefits to online therapy, but most of them have to do with asynchronous communication

So while videoconferencing and Skype are nice technologies, they do little to reduce the costs or inconvenience of seeing a therapist at a scheduled time.

I would argue that e-therapy has not failed to catch on because of a lack of technology or because people didn't have broadband access. It's not like

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Understanding online therapyâ&#x20AC;&#x2122;s stage in the hype cycle helps set expectations of its risks and rewards. Providers must still navigate some complexity around technology, reimbursement, Mark Goldenson legality, and ethics, is CEO of but the benefits have Breakthrough.com, a free virtual never been clearer. The office for online futureâ&#x20AC;&#x2122;s leaders will start counseling. today. Itâ&#x20AC;&#x2122;s time to get enlightened!

video and video chatting was invented yesterday; YouTube has been mainstream for five years and video telehealth services have been available since the early 1990s. It has failed to catch on because people don't really see the benefits of paying out of pocket for a service that their insurance company or government program (like the NHS) will mostly pay for in-person. And the old benefits of e-therapy -- asynchronous communications, disinhibited communications -- have gone by the wayside as video and Skype chats take center stage.

It's not that businesses and clinicians don't sign up for these services (that was never a problem at our e-therapy clinic HelpHorizons.com in the early 2000s). It's that utilization rates for all types of online treatment modalities amongst consumers remain low, because when it comes to our health, people still prefer face-to-face contact whenever possible.

John Grohol is CEO & Founder, PsychCentral.com

E-therapy has helped thousands of patients in the past decade and it will continue to help thousands more in the years to come. But it remains a niche modality in a broad behavioral treatment marketplace that treats millions each year.

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TILT – Therapeutic Innovations in Light of Technology

Marketing Toolbox Susan Giurleo

The Three Most Important Words in Marketing

Marketers often call this the “know, like and trust” factor. Let’s unpack these three words and see how they relate to marketing a practice.

Therapists get known by being useful, helpful and visible where referral sources and/or potential clients spend their time. This could include writing a blog, offering teleseminars, doing a community workshop, or writing in a relevant publication. The goal is to get your name out into the community as someone who is knowledgeable and helpful.

No one works with you if they don’t know you exist. Often therapists sit in their office wondering why their phone isn’t ringing with new clients, and this is typically because no one knows you exist. Sure, maybe you’re listed with a few insurance companies and an online

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listing service, but you have a lot of competition in those spaces. People look at those lists and often just glaze over. They aren’t paying close attention to the names on the list, so it’s the equivalent of not being seen at all.

Know

Marketing (whether online or in your community) requires that people get to know you, what you do, and why it is valuable. Otherwise, no one has any reason to contact you and engage in a working relationship.

Just because someone knows you, it doesn’t

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

mean they like you. So we need to present ourselves and our information in ways that allow people to see some of our personality as someone they want to invest their time with. Always remember that people have choices over who they give their attention to and with our constantly distracted culture, we need to give people compelling reasons to tune in to what we have to say.

TRUST

Being ‘likable’ isn’t necessarily a popularity contest, but a way to get people to look up and notice that you have good, useful information with some style that makes them feel good about spending some of their time and energy with you. People like interesting stories, compelling content in articles and workshops, and a person who sees them and empathizes with their situation.

This is the most important piece of building a relationship with your potential clients. Someone can know and like you, but if they don’t trust you,

they won’t consider moving into a therapeutic relationship with you. The way we build trust in marketing is the same way we build trust in relationships. We are consistent in our behavior and philosophies, we show up when we say we will, we listen to what others have to say and we respond accordingly. An example of building trust in online marketing is blogging. When you have a blog, it is important to post on a regular schedule (consistency), stay focused on one topic (consistency again), respond to comments (listening and responding), and treat everyone who visits with respect. Over time, people who are reading your blog will come to know what to expect from you and feel that you are a safe person to work with. It’s trust that leads to new clients contacting you, not the mere act of “marketing.” When you market in such a way that people can get to know, like and trust you, your practice fills quickly. Often therapists feel uncomfortable with building relationships in this way prior to a therapeutic relationship, but it can be done with ethical boundaries very effectively.

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

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