Archive for the ‘Online Therapy’ Category

Recently Anthony S. Ragusea, Psy.D. offered this informative email to several of us inquiring about this topic. I asked Dr. Ragusea if I could blog his response to all of us and he graciously gave permission. You can read this information at the Breakthrough.com Blog as well.  You can visit his profile at the Online Therapy Social Network.  Enjoy his wise words on a timely topic! Thanks Dr. Ragusea!

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…the Myers-Briggs is indeed online and has been for years, but it is not considered a serious test of personality by experts on test design.  It is not admissible in court and the research clearly shows that it’s not much better than a horoscope.  So let me draw a distinction between serious, rigorously designed tests, and those that are not rigorously designed and thus the designers/publishers are less concerned about the issues I’m about to summarize.  That said, there ARE tests available via computer that are good, solid tests (e.g., the Strong Interest Inventory (career-aptitude test), behavioral rating tests like the CBCL and BASC-2, etc.) but these tests don’t NEED to be administered in person, and also in my experience tests are more EXPENSIVE by computer than paper.  The MMPI-2 is also available for computer administration, but not on the Internet, the client needs to be in the office with the computer.  And it’s more expensive than paper administration, again.  Companies tend to charge high fees for software, plus fees for each test “form,”  and sometimes subscription fees to maintain the service.

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In articles I’ve written, I’ve argued that as of now it is not ethical for psychologists to try to conduct certain kinds of psychological evaluations (like forensic evals) solely via telehealth.

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Here are some of the issues.  One is that some tests MUST be administered in person as they are currently designed because they involve interaction between the examiner and client.  IQ and memory tests, for example, have puzzle pieces, test booklets that require pencil writing and drawing by the client, etc.  In addition, the examiner needs to have control over the testing environment and how the test is administered–the examiner may pick and choose which subtests are administered, for example, or alter the test protocol for a specific purpose.  The examiner also needs to be able to observe HOW the client is behaving and dealing with test items, the test items are only part of the evaluation.  Behavioral observation during test administration is crucial to evaluating people.  For example, the Rorschach Inkblot test could be adapted to computer administration, but then I can’t SEE a potentially schizophrenic client becoming afraid and anxious in response to an inkblot that looks like Satan to the client.  That’s important information.   It might be possible to adapt IQ and memory tests to a computer-based format, but the therapist would still need control over the administration in real-time, and would need to be able to observe the client.

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Another issue relates to STANDARDIZED ADMINISTRATION.  Rigorous tests like IQ, memory, neuropsychological, and others are often designed to be administered under highly specific conditions.  Manuals specify the kind of environment the test should be taken in, where the client should be sitting, exactly what the examiner should say, etc.  Now, some aspects of standardization are better enforced via computer than by a live person, but what can’t happen is that the client be permitted to, for example, take these tests on their laptop in their bedroom with music blasting.  The reason is that it is crucial that all clients take the tests under the same conditions, so that the test validly assesses what’s designed to assess and to permit legitimate comparisons between different subjects who take it.  Changing the protocol potentially ruins the test’s validity.

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The next issue relates to what Mark mentioned, is a computer equivalent to a piece of paper?  I don’t think we have a good body of research on this topic yet.  Intuitively I would agree with Mark, a test that is administered just on paper without any interaction with the examiner should likely be equivalent on a computer (assuming the test-taking conditions are otherwise the same).  But we don’t KNOW that.  For example, does eye fatigue affect performance when taking a test on a computer monitor?  It may depend on the test.  Some tests may need to be entirely re-normed on a population that takes it on the computer, and that’s expensive.

The next issue is very important, and relates to TEST INTEGRITY.  There are hundreds of tests out there, many of them not very well designed, and many that don’t worry about test integrity.  By that I mean are the test items and information about how they are scored and interpreted available to the public.  The Myers-Briggs items, for example, are easily accessible by anyone, as is the scoring and interpretive method.  Many serious, rigorously designed tests require complete test integrity.  It is potentially illegal, and certainly a violation of ethical standards, for a psychologist to make MMPI-2 items, for example, available for anyone to see.  The MMPI-2 must NEVER leave the control of the examiner.  The MMPI-2 is the world’s most well-respected and researched personality test, and part of its validity comes from the fact that whoever takes the test has no prior familiarity with it.  There are examples of people who illegally post MMPI-2 items online so that, for example, people in child custody cases can see them and be coached on how to answer them in a custody evaluation.  Obviously, that can’t be permitted.  Results of personality, IQ, and achievement tests can have extremely serious consequences in real life, so it is CRITICAL that the public does not have access to them and is naive to how the tests are scored and interpreted.  This is why these tests can’t be administered on the Internet, because somebody could copy the items down, take screenshots of items, etc.

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I once consulted with a psychologist who was doing online work and wanted to administer the MMPI-2 to clients located at distant locations.  The only way I could tell her to do it ethically was to have the client take the test at a health clinic in their hometown and arrange with staff there about how to handle the test materials to maintain test integrity.  But that’s difficult and time consuming, and I don’t know if she ever followed through.

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The last issue is one that I touched on earlier–the importance of live observation.  If I’m evaluating a person and the outcome of my eval will have serious consequences, it is absolutely necessary that I see the client in person, at least for part of the eval.  Otherwise, I can’t smell alcohol, I may miss subtle behaviors that are clinically important, I may not be able to see subtle signs of neurological damage like difficulty walking, writing, grasping things, I may miss family interactions that are clinically important, etc.  Even video can’t replace it.  It’s similar to the reasons why the AMA doesn’t want physicians prescribing online to people they’ve never evaluated in person.

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So, to summarize, there are certainly tests that can be administered online appropriately, but others that, as of right now cannot, either because the design of the test makes it impossible to adapt to a computer or because of concerns about security and test integrity.  Sometimes there are concerns that a computer-based test is NOT equivalent to taking it on paper.  Bottom line is that as of right now I can’t administer the core battery of tests that I administer in a psychological evaluation, which really limits what I can do with telehealth.  Other mental health professions aren’t qualified to administer the tests that psychologists are, so they don’t feel the constraint.  But I do think this limitation puts a damper on psychologists’ enthusiasm about moving their practice into the Internet age.

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Anthony S. Ragusea, Psy.D.
Clinical Psychologist

P.S. Be sure to read more about online testing and assessment in our upcoming book —The Use of Technology in Mental Health: Applications, Ethics and Practice due out this fall from Charles C. Thomas Publisher, Ltd.

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I’m a big fan of Eddie Izzard – his acting, comedy and extreme marathon running (43 full marathons in 51 days!). Recently while visiting New York, DeeAnna and I had a chance to see him in the new Mamet play Race at the Ethel Barrymore Theatre on Broadway.

Izzard plays Jack Lawson, a lawyer at a successful firm who is called upon, alongside his black colleagues, to represent a white client (Richard Thomas) accused of raping a black woman. As Mamet explains, “In my play a firm made up of three lawyers, two black and one white, is offered the chance to defend a white man charged with a crime against a black young woman. It is a play about lies…All drama is about lies. When the lie is exposed, the play is over.”

At first glance this appears to be a mystery play about a simple lie by witnesses around where the sequins are from the red dress worn by the accuser in the hotel room where the alleged attack took place. But as their planned case comes together in light of the accused’s blundering press release, issues of racism and sex come to the fore as internal assumptions around what is right and wrong between races and gender clash both within and outwith the lawyer’s office. Essentially, Mamet illustrates a world where there is nothing a white person can say to a black person without feelings of being patronized, upset or simply wrong being incurred. He also demonstrates how this happens between men and women.

So how can online therapists, in relation to not necessarily knowing the colour of their client’s skin, ensure that their internal assumptions and biases around cultures and races (born of upbringing and social environment) do not infect the therapeutic work, either by self-reflection or in Supervision? The written word with clients can often seem stark without tone-of-voice and gesture, so how easy is it to misunderstand a remark made in innocence that a person of a different culture misunderstands as being racist? If the remark is deemed as racist by the client, is this the case? Or is it the case that the therapist is telling himself or herself lies about their attitude to differences in culture, as is the case in Mamet’s play with Lawson’s self-assurance? How important is it to examine and challenge one’s own internal racism in light of not knowing the clients race?

So, Mamet’s play brings a lot of questions about society’s attitudes to difference of race and gender. As well as being very witty in parts and challenging in others, I recommend it as a thought-provoking piece of theatre, as a therapist, an theatre goer, or even as just an Izzard fan!

Kate

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We are working hard on putting together our new OTI magazine, TILT (Therapeutic Innovations in Light of Technology).

The magazine will be online and free, and launched in September 2010. It will be a blend of news, innovations, member profiles, articles, features, marketing toolboxes, news on textbooks, and advertisements of interest. We will have more news on this very soon as the first issue comes together.

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Each issue will include the following:

· Editors introduction and contents (Kate Anthony & DeeAnna Merz Nagel)
· News from the cyberstreet (tweets members, what is at OTI blog, new research news)
· New Breakthroughs column
· Online Therapist column (A Day In The Life)
· Online Supervisor column
· Ethical Dilemmas column
· Feature article 4000-6000 words
· Other article(s) – about 1500 words
· Marketing toolbox column
· Featured Verified website
· Letters/reader comments
· Book descriptions of 3 books per issue
· Advertising and conferences

If you have an article of up to 1500 words that you are burning to get out of your system on any topic related to innovative delivery of therapeutic services via technology (including coaching), please do submit it no earlier than August 1st and no later than August 20th to editor@onlinetherapymagazine.com

We’re very excited at this new development at the Online Therapy Institute and will let you know even more about the content soon!

We look forward to reading your article!

If you have other inquiries about the magazine including advertising options please email info@onlinetherapyinstitute.com

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Kate will be presenting at a conference in Brussels that begins on June 17th and DeeAnna will present at a conference in Pennsylvania that begins June 28th.  Details of both conferences and sessions about online therapy follow:

Employee Assistance European Forum Brussels Conference 2010  See the link for the full agenda.

Best Practices for Providing EA Services via Email Exchange

Ms. Kate Anthony, Founder “The Online Therapy Institute”, President of the International Society for Mental Health Online, U.K.

 2010 EAP-MAP Conference Villanova Conference Center, PA See the link for the full agenda.

Panel Discussion – “Let your Fingers do the Talking: Adding Online Counseling to your Therapeutic Repertoire”
Jane Weiler, LCSW – Program Coordinator, NY Presbyterian Hospital Workplace Services
Mary Ellen Gornick, MA – Senior Vice President – Global Products, Workplace Options
DeeAnna Nagel, MEd, LPC, DCC – Co-Founder, The Online Therapy Institute
Cedric Speyer, MA, MAEd – Clinical Supervisor of E-Counseling, Shepell

We hope to see you there!

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Marina London recently wrote an article for the Employee Assistance Report and kindly mentioned Online Therapy Institute’s Ethical Framework for the use of Technology in Mental Health. Marina, we do appreciate the mention! The pdf download is avalable to read:

Ethical & Legal Considerations of Online Counseling are Ongoing

Read more about the Employee Assitance Report publication here: http://www.impact-publications.com/category/general_info_earn

For more from Marina London, follow her on twitter @IWebU and read her blog at http://www.iwebu.blogspot.com/

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A new article was just published in the Student Assistance Journal! The article is entitled Using Technology to Deliver Career and School Guidance Services: Establishing a Global and Inclusive Ethical Framework  and is co-authored by Harvey Schmelter-Davis, Kate Anthony and DeeAnna Merz Nagel. The article features a full reprint of the Online Therapy Institute’s Ethical Framework for the Use of Technology in Career and School Guidance.  As the abstract states, the article features a framework that strives “to offer a best standard of practice that all career and school guidance practitioners can easily adhere to regardless of particular professional identity, region and/or organization affiliation.”

PDF download:

Using Technology to Deliver Career and School Guidance Services

Schmelter-Davis, H., Anthony, K. & Nagel, D. (2009). Using technology to deliver career and school guidance services: establishing a global and inclusive ethical framework. Student Assistance Journal. 21(3), 26-34. 

The Student Assistance Journal Magazine is published by PRP Media, Inc.

Get Verified!

Do you have a website that offers information, services or products related to mental health?

Online Therapy Institute verifies websites so that individuals and businesses can demonstrate to their audience that their website is in compliance with what OTI considers to be “best practice” and in accordance with OTI’s Ethical Frameworks.

Getting OTI Verified means whether you offer website development and marketing services, you are an individual practitioner in private practice or you own an e-clinic or you represent a charity or educational organization you can indicate to the public that you understand the ethical implications of delivering mental health information and services online.

Website Categories

• Client Services (therapy, counselling. counseling, coaching)
• Therapist/Coach Directory
• Social Network
• Blog
• Peer Support
• Self Help
• Practice Building/Marketing
• Supervision/Consultation
• Education/Professional Development
• Crisis Intervention

You may have a website that fits into more than one category. Or you may have two websites under the same business name. For instance, some people have a private practice website and a separate blog site. We will offer an OTI Verified Seal that you can use on all of your sites. By implementing the items on our checklist that apply to your website categories, you can Get Verified .

• Your seal will be a choice of two styles.
• Each seal carries your company name and the current date.
• The seal cannot be replicated onto another site.
• The cost is $99.99 for the first year and $49.99 renewal each year following.

Instructions

You must have Adobe Reader to Download the following files

OTI Get Verified Checklist ….. OTI Get Verified Notes

• Compare your website to our checklist to be sure your website is ready for verification.
• Read through the notes that offer clarification for items on the checklist.
• Once you are sure you meet the criteria, click Google Buy Now button below.
• Following the completion of the payment process, you will be directed to the application.
• You will be contacted within 10 business days with your OTI Verified Seal.
• Should your website not meet the OTI Verified criteria, we will make recommendations.

Get Verified!

The Online Counselling and Therapy in Action (OCTIA – see www.octia.org.uk) conference (now in its second year), took place in Manchester, England  and online this March 2010  through chat rooms, live video and my own presentation taking place in Second Life with its own chat.

The photograph below shows me presenting to the room of delegates at the OCTIA conference venue, with my own laptop in front of me.  Behind me on the screen is the view from my laptop perspective into Second Life, where I was joined by colleagues from all over the world represented as avatars, who had their own chat facility with me via my laptop and the delegates in the room who were also in Second Life as avatars (hence the laptops in the audience).  The screen on the wall to my right is where I was shown live from the perspective of one of the other delegates in the room in Second Life, with the official OCTIA chatroom being scrolled to the right of the video, where I was also taking part via audio and my laptop via text.

If that description sounds confusing, the point is that I was present in five different realities simultaneously, presenting worldwide.  This groundbreaking event reached four continents – Europe, the USA/Canada, South America and Australia – bringing them together to discuss the use of virtual and mixed realities in counselling and psychotherapy experientially.  To ensure the delegates watching in the physical room and online were truly able to understand what working in mixed realities is like, I wore the same clothes that my avatar is based upon, clearer in the photograph below (with my virtual self centre-front of the screen (from my perspective, hence the back view)).

You can also view a video by John Wilson of OnlinEvents and pics of the event. Jokay, founder of Jokaydia where our OTI office and conference center is located,  took some great pics while inworld. We are ever so grateful for her design expertise and professional support.

The Islands of jokaydia is a virtual worlds community of practice facilitated by Jo Kay aka jokay Wollongong. We are exploring the use of virtual worlds and games for education, arts and social change. You can find us in Second Life, Reaction Grid and our new virtual worlds presence – the jokaydia Grid!

We hope you will visit us inworld! If you’d like to check out Online Therapy Square, and the OTI Headquarters visit: http://slurl.com/secondlife/jokaydia%20II/110/68/24.

Hi Everyone!

I invite you to join me and over 10 other expert speakers for a complementary Therapist Resource Telesummit. Over three days, you will have access to some incredible information on how to create an authentic and profitable therapy business, helping many more clients. I will be discussing online therapy and I am thrilled to be joining such a dynamic group of speakers!

See details here:
Therapists Resource FREE Telesummit March 12 – 14

You’ll discover:

* 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!

Join me!

March 12th, 13th and 14th, 2010
Register and see details here:
Therapists Resource FREE Telesummit March 12 – 14

Wishing everyone the best!

DeeAnna

Exciting development from the OCTIA organising team. On the Friday night of the conference (19th March) there will be a “meet the authors” session before dinner.

I will be there to discuss “Therapy Online [a practical guide] (Anthony and Nagel, 2010), and Dr. Stephen Goss will talk about the forthcoming title “The Use of Technology in Mental Health: Applications, Ethics and Practice” (Anthony, Nagel & Goss, 2010). We will also refer back to the original UK text on the topic “Technology in Counselling and Psychotherapy: A Practical Guide” (Goss & Anthony, 2003).

Anne Stokes and Gill Jones will consider their 2009 book “Online Counselling”, and Jane Evans will discuss “Online Counselling and Guidance Skills: A Practical Resource for Trainees and Practitioners” (2009).

Also great to welcome Jethro Adlington to talk about “Online Therapy – Reading Between The Lines – A practical NLP based guide to online counselling and therapy skills” (2009).

All these books and more are available from the OTI bookstore at http://www.onlinetherapyinstitute.com/bookstore/

Looking forward to it!

Kate