Kate and DeeAnna of the Online Therapy Institute are pleased to announce the launch of TILT Magazine – Therapeutic Innovations in Light of Technology.  This 53 page free online magazine is stuffed with news and views on all things to do with the use of technology in mental health services, and we aim to inform and entertain you along the way.

Featured articles include:

Alice in VirtualLand by DeeAnna Merz Nagel and Kate Anthony

The Writing Cure: Therapeutic Effectiveness via the Internet by Cathryn Heyman and Cedric Speyer

Opening Therapeutic Doors to the iGeneration by Marina London

The first issue is here.  Enjoy.

12:00-1:00PM EST – Dr. Susan Giurleo, Biz Savvy Therapist
Topic: “First Steps to Building Your Innovative, Powerful, Profitable Practice”

1:30PM-2:30PM EST – DeeAnna Merz Nagel, OnlineTherapyInstitute.com
Topic: “Text-based Therapy: An Introduction to Email and Chat”

3:00-4:00PM EST – SCHEDULE CHANGE Brian Whetten, Selling By Giving
Topic: “The One Challenge You Have to Address if You Want to Build a
Six Figure Practice from a Place of Love and Service”

4:30-5:00PM EST – BONUS CALL with Laura Dessauer, Business Success for Therapists
Topic: “Want to Know the Top 5 Mistakes Therapists Make in Building Their Practice?”

How to stop giving your money away to insurance companies and the biggest mistakes therapists make in building a successful fee-for-service therapy business

How to help your potential clients TALK THEMSELVES into working with you and what you’ll need to know to attract way more clients without compromising your values

The mindset shift and business model change you need to learn so you can easily double your current income

How to use coaching to build a fee-for-service practice making six to seven figures a year

The reason why you may be procrastinating in your business and the biggest gift you can offer your clients

The marketing approach that helps your community, while growing your practice at the same time

How to expand your practice using text-based therapy: what you need to know about using email and chat with your clients- everything from encryption, client screening, and cyber-cultural awareness

How to create a signature presentation that leaves your potential clients asking for more

Practical tools you can use to earn expert status and how to utilize technology and marketing strategies to engage clients, build credibility, and earn loyalty

Specific ways social media improves your visibility online and how to use directories and google local business center to gain exposure and attract new clients

How online networking sites and technology can bring therapists, students, and interested professional together in a global web community, maximizing your practice exposure

And so much more!

Unconditional Positive Regard

from Therapy Online: A Practical Guide

Conveying the potential for the therapist to have unconditional positive regard for the client is a process that can often start before any communication actually takes place when working online, through the use of the website to explain what this means and what regard the therapist already feels for the website visitor without having met them. This sounds facile, but it is the tone that is taken via the text while writing the website content that can convey this. Many people make the mistake of writing website content for themselves and how they would like to be, rather than being congruent (which we shall come on to) and writing for their potential client, considering the likely state of mind of the potential client. One can convey to the client that one expects to hear issues and problems that the client may feel embarrassed or ashamed of, and that as their therapist, one will think no less of them for having shared those issues. The website can state up front that the visitor is held in the utmost regard, that they are accepted and that there is a space for them to explore themselves and grow from the experience while being safe from being judged or ridiculed.

It is important to remember that the client can carry the therapist’s input, literally, at all times, and therefore the text must be carefully constructed to avoid any ambiguous meaning that the client can use to fuel any self-fulfilling prophesies that she or he may have. Conveying unconditional positive regard throughout the email or IRC session can aid the interpretation of the text around it, which is often misread, unconsciously, to suit the client’s agenda (Goss and Anthony, 2003). Acknowledging the client’s worth and one’s respect for them often renders misinterpreted text as incongruent and so the client will go back and re-read the text to better understand the meaning, as the misinterpreted text does not seem to ‘fit’with their experience of the therapist thus far. In this way, the regard the practitioner holds for the client and the ability to ensure she or he understands this, underpins the whole tone of the text.

The online disinhibition effect (Suler, 2004), further defined in Chapter 2 often means that the more distressing or uncomfortable issues come up much earlier than they would in face-to-face sessions, and the practitioner may find that they are struggling with this information before they really ‘know’ the client and are able to feel that the unconditional positive regard is inherently in place.This process is crucial to the effectiveness of the therapeutic process – if one is not able to keep the reassurance of understanding and regard in place, the client will feel that they have ‘gone too far’ and they can be lost, since ‘disappearance’ on the Internet is facilitated so easily. It is important to indicate that, in the case of emails and forums, although a word count or length limit is appropriate, it does not mean that the content of the work is limited. Having unconditional positive regard for them means that you can trust that the pertinence of the work will emerge as the relationship grows, and that even where there is uncomfortable work going on at an early stage, this is not only expected, but welcomed.

Many humanistic or person-centred therapists will convey warmth and regard in a variety of physical ways, including smiling, appropriate touching, or leaning towards the client. Chapter 3 will focus on how this is done when working with text, but it is important to point out now that most of the physical tools that the person-centred therapist employs are entirely possible when working without a physical presence in cyberspace, even appropriate hugging (in fact, particularly the hugging (Anthony, 2000)). It should be noted that representation of physical contact or movement should be encouraged when online to assist the development of the relationship and convey the core conditions of humanism. The consistency of this warmth and regard will be important as the work continues, and any withdrawal of it will rebound negatively on the work. It is therefore essential that all representation of being a physical being is natural and personal, so that it occurs without thought or specific intention, unforced.

From Therapy Online: A Practical Guide by Kate Anthony and DeeAnna Merz Nagel.

DeeAnna Merz Nagel is co-founder of the Online Therapy Institute

What is your background?

Educationally, I am trained as a rehabilitation counselor. I received an M.Ed. in Rehabilitation Counseling from the University of Georgia in 1994. Prior to that, I worked in the field of mental health and human services for 5 years. After I completed graduate school I received post-graduate supervision and training working with adult survivors of sexual abuse. For several years following, I worked in many diverse settings- both urban and rural – helping people dealing with poverty, domestic violence, homelessness and developmental disabilities. I spent many years working with child welfare families and foster children offering in-home therapy to families and conducting forensic evaluations to the courts. I am a Licensed Professional Counselor in GA and NJ and a Licensed Mental Health Counselor in NY.

In 1999, I discovered the power of the internet while researching respiratory symptoms. I was sick and a diagnosis eluded my doctors. I turned to the internet for solutions and ultimately, support. I was finally able to talk with my doctor about what I had discovered through support forums and bulletin boards online and I was ultimately diagnosed with Sarcoidosis. From that point on, I realized the inevitable impact the Internet would have in the lives of people all over the world.

Around that time I began offering online counseling through an e-clinic. I joined the International Society for Mental Health Online and had the opportunity to be mentored by pioneers in the field. Eventually, my health improved and I joined the workforce full-time again. For the next 8 years I continued to offer online counseling to clients, maintaining a part-time practice online. In 2005 I was elected ISMHO’s president and I continued to network with my colleagues at conventions and conferences, meeting peer professionals in cyberspace and in person. Regardless of my “day job” online counseling remained my passion. I became a Distance Credentialed Counselor and transitioned from becoming certified to facilitating the DCC trainings. While running an in-home, community based mental health organization, I routinely conducted online field and clinical supervision with employees and contractors.

What do you do now?

Today almost all of my work is related to online therapy and the internet. I am the co-founder of the Online Therapy Institute with my colleague, Kate Anthony. We decided a couple of years ago that we wanted to bring our experience to as many people as possible. To that end, we co-authored a book, Therapy Online: A Practical Guide (just released!) and co-founded the Institute. We offer online training and consultation and promote social networking and the use of Web 2.0 as a way for mental health practitioners across the globe to connect and learn from one another. We offer many avenues for social networking, education and supervision about the impact of technology on mental health. Soon we will be launching a new series of offerings including training and marketing opportunities for OTI members.

I also maintain a small private practice in Atlantic Highlands, NJ and most of my clients deal with issues related to the internet, ranging from cyber affairs and compulsively surfing porn sites to understanding their teenager’s use of social networks like MySpace and Facebook. I spend a lot of time normalizing the internet for some, and teaching appropriate boundaries around the internet for others. Most of my in-person clients also see me online as adjunct to face-to-face sessions. I also conduct e-counseling through a major EAP organization in Canada and I continue to facilitate the Distance Credentialed Counselor training through ReadyMinds (www.readyminds.com).

For a licensed therapist interested in expanding to online services, what are the steps? Is coaching certification necessary? More insurance…?

A therapist or coach who is interested in expanding services to clients online is advised to seek additional training to increase competency. In a “buyer beware” world, it is encouraged that professionals demonstrate to their public that they have the necessary skill and training to conduct services online. At the Online Therapy Institute we offer ethical frameworks for mental health professionals and career and school guidance counselors. In the spring we will release an additional ethical framework for coaches. In January we are launching several online courses for mental health practitioners. For coaches who are also licensed, these courses will offer the necessary training to practice proficiently. Other trainings are becoming available across the globe and professional organizations such as the APA and ACA are offering sessions on topics about online therapy and the use of technology at annual conferences and conventions.

With regard to malpractice insurance, practitioners should check their coverage to ensure that online counseling is not excluded. The practitioner is advised to follow the laws of both the client’s geographic area as well as the laws of the practitioner’s geographic area. While the safest precaution would be to practice within state boundaries, if neither location restricts the practice of online counseling, then it might be presumed that it is safe to proceed. Even so, laws change rapidly and it is difficult to keep up-to-date. Practice due diligence by calling state licensing boards and checking the internet for state laws. OTI offers a Law and Ethics Wiki and we add information as it becomes available. Document efforts of discovery in the client’s file.

In OTI’s ethical framework for mental health, screening for clients who are not appropriate for insight-oriented therapy is advised–makes sense. What happens if an online therapy client emerges as being suicidal, substance abusing, in crisis, or otherwise not appropriate during the course of treatment?

Just as with face-to-face counseling, appropriate client screening is essential. This can occur via an initial consult online or via telephone. In addition, I use the same questionnaire with my face-to-face clients as I do with my online clients. I ask questions related to psychiatric history, medical issues, immediate concerns, medications and I ask about the client’s experience with technology. I state in my informed consent that the client and the therapist utilize the first couple of sessions to assess the client-therapist fit. With regard to crisis, as soon as I receive a new client, I research local resources, and police/fire numbers. Then I follow much the same protocol I have followed when working crisis hotlines. In fact, I encourage practitioners who want to work online to take a crisis hotline training through an agency in their local community, Hotlines have been doing crisis work for decades so handling crisis via distance is not a new concept. Of course, this protocol changes depending on the setting. For instance, the EAP I contract with offers 24/7 support through a crisis call center so the client has access to that number and from the beginning.

Other referrals for services such as substance abuse and psychiatric consults are made as necessary just as in face-to-face work. The key is knowing the client’s geographic area and having a comfort level with researching resources online and developing a peer professional network when such referrals are needed. Networking online is as important to the online therapist as networking within one’s local community for a face-to-face therapist.

Have there been nightmare scenario online therapy legal cases? How are courts weighing in on the subject (if at all)…?

I am not aware of any case law to date that is influencing online practice. But that is always subject to change! In my opinion, following state laws, avoiding dual relationships and maintaining confidentiality online are “hot spots” that could easily lead to legal trouble. All correspondence that would be considered part of the psychotherapy record should be encrypted and practitioners are wise to consider how they manage their online presence with clients given the advent of Web 2.0 and social media.

Any final words of wisdom for therapists interested in offering online services?

If you are interested in conducting online therapy or online coaching, educate yourself. The nuances online and with other forms of technology are real and as with anything we add to our intervention toolkit, we should be skilled and prepared while also working within our scope of practice. And remember, if you are a coach but you are also licensed as a mental health practitioner, your license is the standard of care to which you should adhere. I have spoken with many therapists who think that if they call themselves a coach, then they can avoid any liability that may come with conducting online therapy. That simply is not true.

I hope this is the decade that online therapy is embraced as a viable alternative for those who so choose. Telepsychiatry is already offered in rural communities across the country and now the military is offering online therapy through TriCare. Employee Assistance Programs are offering online interventions and the research is showing efficacy in online methods of delivery. The time is now. We are no longer asking “Should we offer online therapy?” We are now asking, “How do we offer online therapy?”

If you are interested in continuing this dialogue and other similar conversations, join us at www.onlinetherapysocialnetwork.com! We would love to have you!

Find DeeAnna Merz Nagel online at www.deeannamerznagel.com and www.onlinetherapyinstitute.com