Saving the Game The Use of Gaming within Psychotherapy

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 5, May 2011 

TILT Magazine Staff 

Managing Editors Kate Anthony & DeeAnna Merz Nagel 

Magazine Production Coordinator Agnes Ikotun 

Magazine Design and Layout Delaine Ulmer 

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. 

T I L T M A G A Z I N E M a y 2 0 1 1

TILT – Therapeutic Innovations in Light of Technology 

NEWS 

from the 

CyberStreet 

The Cyberstreet is here to keep you informed of news even if you haven’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! 

6 T I L T M A G A Z I N E M A y 2 0 1 1

w w w. o n l i n e t h e r a p y i n s t i t u t e . c o m 

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! 

At the OTI blog, you can click to read an interview with Kate and DeeAnna that was recently published 

in the British Association for Counselling and Psychotherapy (BACP)’s Workplace Division’s Journal. 

DeeAnna also shared many useful resources that came from a presentation on the topic of the future 

of online therapy she gave at the Psychotherapy Networker Symposium. You can read a write up of that 

Symposium, and also one of the recent OCTIA conference (Online Counselling and Therapy in Action) 

held in Bristol in March, at which Kate presented the same material almost simultaneously on the other 

side of the world! 

At the member blogs, there are posts about spiritual autobiography, counseling in Second Life, myths 

about telephone counselling, and updates on the state of therapist regulation in the UK. We are pleased 

to have over 900 members of the social network now, and look 

forward to hearing more from everyone via the blog and forum 

features. 

Member news… 

In an experimental form, 

Olusegun Adebowale has 

commenced the establishment 

of online guidance and 

counselling services for 

his university. Specifically, 

prestigious Nigerian Obafemi 

Awolowo University has 

established (as a Ph.D. project 

and thesis) a free online 

guidance and counselling 

service for students. This will enable full-time 

students as well as distance learning students to 

have unrestricted access to counselling services at 

any time of the day and from anywhere the Internet 

is accessible. For more information, visit www. 

oauonlinecounselling.org. 

T I L T M A G A Z I N E M A y 2 0 1 1 7


BY Joy Waddington 

Experiencing Presence 

Some Thoughts 

I had a strange experience when I was reading issue 3 of TILT Magazine. Not just the 

usual “oh that’s interesting”, but a cascade of related responses, each one adding 

to the previous one as I read through the pieces. The authors in question and the 

phrases in their pieces were: 

Paul Silverman – Navigating Conflicts by Email: “Email communicates words and 

words only” 

Jean-Anne Sutherland – Reel Culture: “What is ‘real’ to one individual or group may 

indeed appear crazy to another’ 

Ralph Friesen – A Day in the Life of an Online Therapist: Recognising ‘presence’ 

of each other in their written words: “…and in this experience of mutual presence – 

which sometimes seems to create a Presence with a capital ‘p’…” 



My first response was my 

disagreement with Paul 

Silverman’s statement that 

email communicates words and 

words only. I was still pondering 

why I disagreed with this as I 

kept on reading through the 

magazine. I was thinking about 

‘energy’ and how directed 

thoughts and words carry 

power. I was wondering how 

well this belief would go down 

amongst the online counselling 

community when I read Jean- 

Anne Sutherland’s phrase and 

realised she had put my thought 

on the page. My beliefs, whilst 

real to me, may indeed seem 

crazy to others. 

As I realised that my own 

thoughts were focussing on my 

experience of ‘presence’ online, 

I read Ralph Friesen’s piece and 

there again, he had put my 

thoughts on the page when 

he described his experience 

of mutual presence between 

client and counsellor seeming 

to create “Presence with a 

capital ‘p’”. 

So if emails communicate words 

only, how can we possibly 

experience ‘presence’ and then 

‘Presence’, online? 

As a counsellor new to online 

work, my own experience of 

presence online came very 

powerfully one evening having 

just sent off a reply to an email 

client I had been working with 



for a few weeks involving one 

email exchange per week. I 

had such a strong sense of this 

person, not just in the way they 

had described themselves to 

me but fully, almost physically, 

as if we had just been in the 

room together working faceto-face. 

At this moment, 

doubts I had had about 

the value and authenticity 

of online counselling were 

completely dispelled. Through 

my experience of presence, I 

had experienced the clientcounsellor 

relationship and 

realised that this could be as 

powerful and therapeutic as 

face-to-face. 

I’m writing here about my 

experience rather than theory 

but I see presence as operating 

at different levels: 

• Having an online presence; 

for example having a 

website or Facebook page. 

Being known about or seen 

but with no interaction. 

• Experiencing the sense of 

someone you have met 

as having ‘presence’. You 

remember them for some 

reason. They have had 

an impact on you. This is 

presence seen and felt. 

• Presence as an instinctual 

‘gut’ feeling; for example, 

knowing that you are being 

watched by another being 

(animal or human). This 

is presence unseen but 

strongly felt, at more of a 

distance but with awareness 

that someone is focussed on 

you. 

At one level ‘presence’ is clearly 

visible but not felt, at another 

level, not at all visible but 

strongly felt. The latter can 

happen when two or more 

people are deliberately tuned 

into each other (not necessarily 

at the same time) and have a 

connection - in this case, their 

writing, which is deliberately 

written and sent specifically to 

each other. 

It is thought and feeling coupled 

with intention, focussed like 

a beam towards another 

person which carries presence 

through the written words. 

Here, presence is energy around 

and attached to the words. The 

words carry presence across 

time and space, between 

computers and people. Words 

are thoughts (energy) given 

form and purpose. Through this 

they crystallise presence. 

This beam of presence can also 

carry the very essence of the 

sender and whether their words 

were written simply as the ‘right 

thing to say’ or with true feeling. 

What is then transmitted with 

this writing becomes much 

more than the words. I think this 

is one reason why words and 

phrases can be ‘misinterpreted’ 

by the recipient of them; not 

only are they reading them 

within their own context of 

beliefs and life experience 

but the words come wrapped 

in the ‘energetic state’ of the 



counsellor and whether they 

were written from the heart. 

This becomes particularly 

important in exactly the 

situations that Paul Silverman 

is describing during times of 

conflict, when there may be 

strong emotions being felt. 

Whilst the recipient of the 

email may not see the physical 

body language of the sender, 

they will receive the energetic 

expression of their emotion 

being felt through the words if 

this has not been dealt with in 

some way before writing. 

Presence, like other qualities 

necessary for creating a 

therapeutic relationship, is 

hard to define and to describe. 

It is a feeling sense and cannot 

be directly taught (except in 

terms of focussing the senses 

on the ‘here and now’) but it 

is recognised as soon as it is 

experienced. 

About the author 

Here I have tried to describe my 

own experience of presence 

online, and my beliefs that our 

words carry much more than a 

simple expression of language 

when they are focussed and 

targeted to a known or named 

person. 

Joy Waddington is a counsellor who was, until recently, working for a 

small UK company supporting people who have experienced trauma. 

She is currently in the process of developing her own online and face 

to face work using Therapeutic Writing and Journal Therapy. She lives in 

North Yorkshire, England. 


Online Therapy Institute is proud to announce 


online workshop modules! 

We offer several modules 

comprising 5-10 clock hours 

of learning on many topics! 

Introduction to Cyberspace: A Primer for Helping 

Professionals 

Relationships in Cyberspace: An Introduction for 

Helping Professionals 

The Online Therapeutic Relationship: Theoretical 

Considerations 

Ethical Considerations of Online Therapy 

Working Therapeutically Using Asynchronous 

Email 

Working Therapeutically Using Synchronous Chat 

Working Therapeutically Using 

Telephone and Audio 

Using Video Conferencing to Conduct Online 

Therapy 

E-Therapy: Asynchronous Email/Web Board 

Therapy, Cyber-culture, Ethics 

More Information 

We have also launched a new 

Certificate in the Therapeutic Use 

of Technology. This is the first in our 

Certificate Programme series. 

This Certificate is a 40 clock hour facilitated course and truly prepares the 

mental health practitioner in the delivery of online therapy. 

More Information 

REGISTER 

TODAY! 

C E / C P D h o u r s a r e a v a i l a b l e 



Research Review 

Could the Internet save 

through improved mental h 

that there is similar relative expenditure in 

other countries – and consequent potential 

cost-savings to be had. 

In the USA in 2009 what was known as the 

“American Recovery and Reinvestment Act” 

directed more than $US7 billion to make 

broadband Internet more widely available and 

used. The elderly were a particularly targeted 

population, as a group among whom use of 

broadband Internet remained fairly low in 

comparison with other groups. George and 

Sherry Ford (Ford and Ford, 2009) studied more 

than 7,000 American elderly people to evaluate 

the impact that the Internet had on their mental 

health. Mental well-being was measured with 

an eight-point depression scale, the results 

being subjected to a battery of statistical 

tests. Their findings suggest that Internet use 

can positively affect the mental well-being of 

elderly Americans, suggesting that it leads to 

an approximate 20% reduction in depression. 

This finding has some remarkable implications. 

Ford and Ford report that “as depression is 

estimated to cost the United States about $100 

billion annually, expanding Internet use among 

the elderly may have significant economic 

payoffs” (Ford and Ford, 2009, p.1). It is notable 

In the UK, for example, depression costs 

£887million, higher than the costs of treating 

hyper-tension or diabetes. The World Health 

Organisation reports that depression affects 

121 million households around the world, it 

being among the leading causes of disability 

and the 4th most costly disease (WHO, 2010). 

Combined with costs of depression, reported by 

Luppa et al in 2006, of $US1000 to $US3700 per 

case this suggests a global cost of depression 

between a staggering $US121billion and 

$US4.4trillion, even at 2006 prices. 

Furthermore, we should note that less than 

25% of depression sufferers have access to 

effective treatments, falling to less than 10% in 

some countries (WHO, 2010). If the findings of 

the Ford and Ford (2009) study were replicated 

among other sectors of the population, some 

might speculate that this suggests a potential 

for the Internet to slash 20% of the costs of 

care for depressed people, perhaps especially 

among the elderly. 

That would put the potential net impact of 

the Internet at a figure approaching $US900 

billion. When we put together the trend of 



DISTANCE CREDENTIALED COUNSELOR 

(DCC) TRAINING 15 CE hours 

BECOME A DCC COUNSELOR 

SIGN UP TODAY FOR A DCC TRAINING WORKSHOP AND EARN 15 CE HOURS 

UPCOMING 2011 DATES: 

9/22 & 9/23 - Lyndhurst, NJ 

10/13 & 10/14 - Atlanta, GA 

10/25 & 10/26 - Denver, CO 

UPCOMING 2012 DATES: 

4/19 & 4/20 - Albany, NY 

FACILITATOR: 

DEEANNA MERZ NAGEL, LPC, DCC 

WORKSHOP FEE: $595.00 

Discounts available if you REGISTER EARLY 

WHAT PROFESSIONALS ARE SAYING: 

“I would recommend the DCC Training 150%. It was the best training I have 

ever completed and you will be given ALL the tools, resources and knowledge 

you need to get started.” Thomas Tsakounis, MS, LGPC, NCC, RH(AHG) 

“What a PHENOMENAL Training! DeeAnna Merz Nagel provided invaluable 

information on using encryption to protect confidentiality, how 

to maintain appropriate relationship boundaries, and how to screen clients for 

suitability of receiving these modes of delivery. It was by far the best workshop 

I’ve ever attended!” Debra D., MSEd, LPC 

CONTACT LISA MILLER @ LISA@READYMINDS.COM OR CALL 888.225.8248 FOR MORE INFORMATION 



Research Call 

Emerging Technologies & Families Survey (SETF)© 

A team of researchers at the University of Deusto in 

Bilbao, Spain, under the leadership of Dr. Gonzalo 

Bacigalupe, is studying the impact of information 

communication technologies (ICTs) on families. 

The survey is directed to trained family therapists, 

family psychologists, and family work clinicians in 

Spain and North America (Canada, US, Mexico). 

We are interested in learning about your views on 

the subject of ICTs and families since you have first 

knowledge of what couple and families are bringing 

into the therapeutic conversation. 

This survey has been approved by the Ethics 

Committee at the University of Deusto. It should 

take less than 5 minutes to complete. We truly 

appreciate your participation! Answering the survey 

indicates that you have read and understood the 

description of the study and agree to participate. 

If you wish to participate in a raffle of an IpodTouch, 

we are asking you to add your email. To preserve the 

anonymity of participants, the email information 

will be delinked from the survey data. 

If you are willing to volunteer for a follow-up 

interview, please provide your email. 

Check Out the 

Online Coach Institute! 

Resources for Coaches 

and Helping Professionals! 

For further questions, please contact: 

Gonzalo Bacigalupe, EdD, MPH. Ikerbasque 

Research Professor. gonzalo.bacigalupe@deusto. 

es. University of Deusto, Faculty of Psychology and 

Education, Aptdo 1, 48080 Bilbao, Spain. Phone/Fax 

34.944.139.085 



Ethical 

Dilemma 

Reader 

Responses 

IN THE LAST ISSUE WE ASKED: 

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?! 

I would take the conversation offline. If this is a 

current coaching client then I would have contact 

information. Getting my client on the phone to 

determine any safety risk would be my first priority. 

I am assuming that my psychologist license is up to 

date and would explain the difference in coaching 

and therapy to the client. After this has been 

defined more clearly I would request that we take 

the relationship out of the coaching arena and put 

it in the therapy arena. 

I am not sure I would reply as a 

tweet? But to ask them to privately 

contact me or a professional for 

risk assessment. I am licensed, 

but would never talk about these 

issues online in view of all. I may 

have understood this incorrectly. 

Hopefully, they would have been 

taught self-care? 

Reply by 

Jamie L. Summers Stacks 

Reply by 

Kathleen Blumentritt 



Since I do not believe in compartmentalizing my skills 

(as humanistic therapist and life coach) and believe that 

the most ethical thing one can do to respond to a client 

is to help and support in any way possible, I would ask 

the client what kind of help s/he wants from me, listen 

to what is going on with him/her, ask whether s/he is 

feeling suicidal in which case I might suggest that s/he 

check into the nearest facility, but, short of that, I would 

coach on the ability to be aware in the present moment 

and what choices s/he has which might include seeing 

a psychopharmacologist if the hopeless feeling is not 

situational but appears to be chronic. I believe that it 

is unethical to ask a practitioner to pretend they don't 

have a skill set just because they have chosen to operate 

more in the coaching domain. I have often found it very 

useful to have both sets of abilities to really help a client 

move forward. 

I would invite the client to bring the 

conversation offline and definitely 

out of the social media sphere. As a 

psychologist who is now exclusively 

a coach, I would explain to the client 

that we can try and assist them 

using the coaching paradigm, but 

if difficulties persisted beyond the 

frame of coaching I could facilitate 

a referral to a therapist if desired. I 

would also have a social media policy 

in place that I share with coaching 

clients before we started working 

together, letting them know that I 

don't interact with private clients in 

social media to protect their privacy 

and anonymity. 

Reply by 

Niela Miller 

Reply by 

Glynis Sherwood 

I would respond via a confidential means (not twitter - I would only use the means of contact my 

client and I had contracted for if things arise between sessions - probably confidential email). 

I would express support and my encouragement to raise the issues at our next scheduled session. 

As a a message like that could (possibly) be an indication of very seriously low mood, I would also 

ensure that I briefly repeated information I include at contracting about sources of emergency 

help (such as Samaritans, Befrienders International etc) just in case there is a risk of serious harm or 

even suicide, given that most suicides happen after the person has given some kind of indication of 

severe distress, often to a professional and, sadly, too often such hints are not picked up on directly. 

I would also be raising with my client the appropriateness and risks of contacting me about this 

kind of thing through twitter, of course. 

Depending on the nature of our contract I would also be thinking about possible onward referral 

to therapy, to keep our work focused on the coaching role as, in this instance, my role is clearly as 

coach not therapist. However, there can (at least sometimes) be a large overlap between therapy 

and coaching so if it were within both contract and my skill set I would keep working with what the 

client brings 

20 T I L T M A G A Z I N E M A y 2 0 1 1 

Reply by 

Stephen Goss


I believe that many issues that might be seen as psychological in nature can be addressed from 

a coaching perspective since a good coach can use the coaching model to help the client access 

effective strategies for change. That being said, the above statements "Depressed. Hopeless. 

Help me." should stand out for any therapist- turned-coach and should take them out of their 

coaching role for long enough to properly assess risk. Staying in a coaching role for the above 

would certainly not be advisable. My job would be, at this time, to obtain the support necessary 

for the client and that would involve getting them connected with the services they need, i.e. 

Medical, psychological, counseling, etc. Once the situation is stabilized the client can continue 

with coaching, if desired, but I would most likely talk to the attending professional (with client 

consent of course) to determine whether the timing is right to return to coaching. 

I'm embarrassed to say that when I initially read the dilemma I somehow missed the fact that this 

was a tweet! So yes I completely agree with Glynis (editor’s note: see above) that Step #1 is to 

take the conversation offline. This is great example of how having a Social Media in place (which 

I now do) is crucial. The likelihood that such an even would occur is then significantly lessened. 

Reply by 

Jeffrey Fisher 

One issue here is whether the coach still felt 

competent and interested in introducing 

psychotherapy into the relationship. 

Assuming that is the case, I would contact 

the client and explain that I am a licensed 

Psychologist (assuming my license is still 

active) and ask if he or she is interested 

in bringing psychotherapy into our 

relationship. I would explain that it would 

not preclude coaching, but that it does 

change the nature of our relationship in 

important ways. I would try to explain the 

benefits and problems with choosing to 

do therapy with me as opposed to finding 

another therapist. Ultimately, I would let the 

client decide. 

Reply by 

Tim Desmond 

I would help. As you said the credentials and 

experience are there. So there would be no 

ethical boundary not to. The client already 

has a bond with you and obviously trusts you 

and turns to you for help. He or she might not 

go to another professional to get help from 

someone else that he or she has no bond 

with at all. And it would probably be a one off. 

You don't advertise yourself as a psychologist 

anymore, so most of your clients will come to 

you as coaching clients. 

Reply by 

Mieke Haveman 

Longer replies and further discussion are 

available at http://onlinetherapyinstitute.ning. 

com/forum/topics/coaches-and-therapistsethical 

thanks to everyone for their contributions! 



What 

Hi Everyone! 

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. 

Would You Do? 

dilemma 

You have been seeing your client for a few months and 

he discusses his blog frequently. You have his explicit 

permission to view the blog and have done so in the 

past, both feeling comfortable with the content and the 

boundaries surrounding discussing therapy on it. At the end 

of the last session, your client seemed uncomfortable, edgy 

and worried. He states “perhaps you should visit my blog 

again…” 

As agreed within the contract, you do so and while 

nothing your client has said about the therapy may be 

considered damning or destructive to the relationship 

and the therapy, you discover that it has been linked 

to by many mental health sites and gone viral, 

inviting thousands of comments, many of which are 

defamatory. 

What would you do?! 

Weigh in at the OTI Social Network’s Discussion 

Forum! 

http://onlinetherapyinstitute.ning.com/forum/ 


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. 


Saving t 

The Use of Gaming w


he Game 

ithin Psychotherapy 

By Mike Langlois 

Luke had begun playing 

World of Warcraft with his then 

partner and friends about 2 

years ago. In the course of that 

time, Luke and his partner had 

tried unsuccessfully to adopt 

a child, which he believes was 

thwarted by a judge who did 

not think gay couples should 

marry. He and his partner 

saw the legalization of gay 

marriage and its overturn in his 

state, CA. His partner had lost 

his job, and their relationship 

subsequently deteriorated, 

ending in divorce. Throughout 

all of this Luke was able to stay 

connected and supported by 

his friends and other members 

of his guild. He attributes his 

ability to move on and be 

ready for the next phase of his 

life through the enjoyment of 

WoW and his guilds. 



Sam credits a video game with saving his 

life. He was working abroad in Qatar in the 

Middle East. He told me how he had fallen 

into a profound loneliness and depression 

shortly after moving out of the country. His 

work began to suffer, and he had a hard time 

dealing with the isolation. All his friends were 

back in the US, and he had a hard time being 

in touch with them. He had seriously begun 

contemplating suicide. Then he remembered 

that his friends had been pestering him to try 

this game, World of Warcraft. He had nothing to 

lose, so he loaded the game onto his computer. 

He found the game very compelling, and was 

even happier to discover that he could log on 

to the same server as his friends at home. They 

were able to raid and talk together for the next 

9 months he was living in the Middle East, and 

his isolation and suicidality became a thing of 

the past. 

Matt, a young man in the elevator, is wearing 

his gaming regalia of a Starcraft T-Shirt. “How 

are you enjoying the convention?” I ask him. 

He looks glumly at me and points to his badge 

which said “TEAM 543” on it. “I came in 5th,” he 

said. 

“Congratulations,” I said, adding, “5th place 

isn’t bad.” 

“5th place you only win $1,000,” he said, “1st is 

$25,000.” Turns out that Matt has flown across 

the country to participate in a tournament. 

So much for gamers as slackers who have no 

ambition or work ethic, I think. 

* * * * * 

Millions of people like Matt, Luke and Sam play 

video games. Many of them are resilient people 

dealing with some pretty big life problems. They 

haven’t checked out of reality, instead they lean 

on the virtual world and the human relatedness 

they find through it. I have met people willing 

to strike up a conversation with me as we wait 

in line at a convention. I have seen fathers and 

their adolescent sons and daughters spending 

quality together. In fact I have encountered 

couples of every configuration and entire families, 

all spending time together, not avoiding human 

contact. 

When psychotherapists begin working with 

gamers and exploring their in-world experience, it 

can be a bit overwhelming. There is so much new 

language and learning when trying to imagine 

virtual worlds that you’ve never seen. What’s a 

raid? Why would someone go on quests? And 

aren’t guilds something that artisans used in 

the Middle Ages to control the market? I often 

encourage therapists to take the time to use the 

free trial membership on WoW or other games in 

order to become immersed in the virtual world 

(and hopefully have fun!) for a little while. 

But one thing that can get overlooked in the 

exploration of the technology is the exploration of 

feelings, and one reason that this gets overlooked 

is because therapists inadvertently trivialize the 

experience of feelings experienced in-game or in 

social media. Virtual worlds create real feelings, 

and we need to remember that when working 

with gamers. So who are gamers exactly? 

Many gamers are adolescents; according to the 

Pew Research Center in 2008 fully 97% of teens 



ages 12-17 play computer, web, portable, or 

console games. Ninety-nine percent of boys and 

94% of girls play, and 50% played as recently as 

yesterday. 

But if you are thinking that all gamers are 

adolescents though, think again. A 2008 report by 

the Pew Internet and American Life Project found 

that 53% of American adults play video games as 

well, a fight of these almost daily. Of these the 

majority was the under 30 group at 81%, but all 

other age groups reported significant numbers 

from forty-somethings at 60%, baby boomers at 

40% and 65 and beyond at 23%. 

Nor was there a significant disparity in terms of the 

racial categories the researchers looked at. 51% of 

Whites reported playing, 51% of Blacks, and 63% 

of Hispanics. And in terms of income brackets, 

more than half of Americans played video games 

regardless of income. 

In addition, the more education Americans have 

the more likely they are to play video games, from 

40% with less than a high school degree to 57% 

with a college degree or more. And whether you 

live in rural (47%), urban (56%), or suburban (53%) 

America, there’s a good chance you’re playing 

video games as well. 



In other words, anyone you meet could be playing 

video games regularly. These gamers are people, 

and they have feelings. Even if the stereotypes 

were true (and they’re not) that all gamers are 

autistic, people on the spectrum have feelings too. 

Gamers get excited when they down a boss, upset 

when someone says something racist in guild 

chat, and happy when someone whispers them 

that they did a good job or tells them a joke. There 

is a world of real feelings in those virtual worlds, 

and we psychotherapists need to pay attention to 

them. 

Do you ask gamers about how they get along 

with their guildmates as well as their roomates 

or partners? Do you explore their relationship to 

their raid leaders as well as their parents and other 

authority figures? If not, you are missing a whole 

lot of significant information, and it is only an ask 

away. Gamers may be reluctant to talk about their 

in-world feelings and relationships because of 

past disinterested receptions, but don’t imagine 

they don’t have them. 

First, there is the problem of cultural translation. 

The study was conducted in Singapore, and as 

one of the researchers acknowledges, “In the US, 

we didn’t follow the kids across time, so we don’t 

know where that threshold is across each culture 

or if there is a certain amount that is too much.” 

And we also don’t know the cultural variables 

when we compare Singapore, a city-state, with 

other countries. Children in urban areas often 

play more video games due to the safety concerns 

of living in an urban area. 

But more importantly, let me share with you some 

other statistics, more close to home. Using a far 

As if dismissing video games from the therapy 

office weren’t bad enough, the media regularly 

hypes scientific research that pathologizes 

gamers. A recent study in the February 2011 issue 

of Pediatrics came out reporting that children are 

using video games “pathologically,” and that this 

is a global problem. The study reported that out 

of a sample of 3,034 children, 9% of them could 

be considered “pathological” in their play, which 

the researchers found “some serious problems 

– including depression, anxiety, social phobias 

and lower school performance – seemed to be 

outcomes of their pathological play.” A closer look 

at the study however, could indicate something 

very different. 



greater sample of over 10,000 teens ages 13-18, 

the National Institute for Mental Health found 

that over their lifetimes, 20% of the children had 

“suffered from a mental disorder with symptoms 

severe enough to impair their daily lives.” An earlier 

study with over 3000 younger children found that 

13% of the children met the criteria for one or 

more mental disorder. This figure is actually down 

from the Joint Commission on the Mental Health 

of Children, which in 1969 found that 13.6% of all 

children had “emotional disturbance.” That’s long 

before the first video game came out. If anything 

the numbers have gone down with the advent of 

better treatment, and I might add, the advent of 

video games. 

So yes, close to 100% of children in the U.S. play 

video games, and yes, somewhere between 13- 

20% of U.S. children have some mental health 

issue, but that’s because the statistic correlates to 

a pretty consistent percentage of the population 

over time predating video games entirely. And 

even if the first study from Singapore were 

comparable, we could make the argument that 

kids in Singapore play even more video games 

and have even less mental health issues than kids 

in the U.S. 

The stigmatizing of gamers leans upon the 

stigmatization of mental illness, which can be 

challenging, heartbreaking, costly and different 

from a societal norm, but it is not bad. Mental 

illness is a prevalent health condition, like other 

prevalent health conditions such as, per the 

CDC statistics, Diabetes (10.1%,)High Cholesterol 

(15.6%,) Hypertension (30.5%,) and Low Back 

Pain (25.6%.) Gamers and people with mental 

illness do have something in common: they are 

both marginalized and socially stigmatized by the 

larger population. 

Like the historical stigmatization of psychosis, 

today’s therapists often talk about a video gameplaying 

patient’s reality testing, and their ability to 

participate in real life. Real life, like many abstract 

concepts, is often misused. 

I often hear therapists describe gamers as people 

who are trying to avoid “real life” by using games. 

The implicit judgment in this statement is that 

games are not a part of reality, and therefore are 

less than. But this seems like a false dichotomy 

to me; in many ways similar to the way therapists 

often talk about how therapy is not real life. 

Of course it is! Therapy has distinct rules and 

boundaries, and it is a rarified form of relationship, 

but it is not of a different substance than that 

of “real life.” If it were truly a different thing, it is 

unlikely that patients would gain anything useful 

from it. 

By the same token, games are part of real life. 

World of Warcraft is inherently social, there are over 

12 million real people playing it all over the world. 

Gamers deploy real skills to solve real problems 

and their neurological responses to an “Epic Win” or 

“Fail” are real physiological responses. This is not to 

say that the gaming part of a patient’s real life can’t 

get out of balance with other parts. But it is not a 

given, and it is not different from the way others 

use their ego defenses. We all use repression and 

sublimation to cope with the conflicts and anxiety 

that occur in daily life. I recall a clinical professor 

of mine who sublimated her murderous impulses 

by reading murder mysteries. Hurling fireballs in 

WoW is an excellent way to prevent oneself from 



hurling objects or insults in real life. The defenses 

are there for a reason, and they are not inherently 

bad. 

If you are a therapist and you are seeing your 

patient who games as someone who is not paying 

attention to their “real life,” ask yourself if you are 

not perhaps projecting. Many therapists have 

a great deal of difficulty finding balance in their 

own lives. They may find it easier to say that a 

gamer needs to “get a life,” than to realize that 

they are projecting their own feelings of disregard 

for themselves onto gamers. By this I mean that 

therapists often overvalue the work they do in 

proportion to their family, friends, and other 

areas of their lives. For example therapists often 

will see too many patients at a sliding scale fee 

while their children are impacted by their lower 

income. They overvalue their therapist role and 

their parental role suffers. Other therapists may 

have a difficult time making time for friends or 

having conversations that go beyond 45 minutes; 

they may listen but not share of themselves. And 

still other therapists may neglect exercise and 

meditation because they don’t have the time, but 

overbook their work schedules. 

Before we can help gamers appreciate the need 

for balance in their lives, we need to empathize 

with what they are doing. They are relying on the 

areas of strength they have in themselves when 

they game, and are reluctant to go to the areas 

that need development. So let’s be careful if we 

have to use the idea of “real life” at all. It is often a 

veiled judgment, and veiled judgments are often 

projections. Let’s go with Wittgenstein here, who 

began his Tractatus Philosophicus by stating “The 

world is everything that is the case.” Privileging 

some aspects of life over others is often the first 

step towards the oppression of others, be it race, 

gender, orientation, class, or I would suggest, 

gaming. And it certainly won’t help our patients 

get any better. 

Hopefully the case has been made to investigate 

the personal realities of people who use video 

games in non-stigmatizing ways, to explore rather 

than pathologize. But should we stop here or take 

the next step? Having begun to see how therapy 

can help gamers have better lives, what if we dare 

to ask the question “Can understanding video 

games make better therapy?” 

* * * * * 

In the 19th century Sigmund Freud revolutionized 

the fields of neurology and psychiatry. Whether 

you agree or disagree with the particulars, 

psychoanalytic theory, and the psychodynamic 

theories that sprang from it changed the way we 

understand the human mind. Freud pioneered 

our understanding of the psychosomatic illness, 

conflicts, drives and the unconscious, to name but 

a few of the ideas that still influence theory and 

practice of psychotherapy today. 

The way Freud came to understand and then 

attempt to help us understand these ideas was 

by applying other theoretical models to our 

psychology. The industrial revolution, with its 

steam-powered hydraulics and locomotives 

powered by internal pressure, heavily influenced 

his beginning work of trauma affect and drive 

theories. His famous topographic model of the 

psyche, with its strata of conscious, preconscious 

and Unconscious, was inspired by the advances in 



Gamification is the act of using the elements of 

video game design and applying it to other parts 

of human existence. We have seen gamification 

begin to be used in businesses like IBM and 

written about in the Harvard Business Review. 

MacDonald’s has been using gamification with 

its’ Monopoly game for years. The Army has been 

using video game technology to gamify our 

defenses. Socially Serious Games like Against 

All Odds are being used to educate people 

about human rights and global conflict. So can 

gamification be applied to psychotherapy? 

I think so. 

geology and archaeology of his day. In short, the 

technological advances of his time informed and 

shaped the way he thought about and worked 

with people. 

Now we are in the 21st century, which is new 

enough that saying it still fills us with amazement. 

The revolutions in technology continue, and I want 

to begin applying some of these technological 

advances to my theory and practice. I have blogged 

a lot about games, and today I want to discuss the 

application of game theory in understanding the 

human psychology. 

In her new book Reality Is Broken, Jane MacGonigal 

reminds us of the concise yet brilliant description 

of what a game is according to Bernard Suits. 

Suits defines playing a game as “the voluntary 

attempt to overcome unnecessary obstacles.” An 

example of would be chess where we agree to use 

the playing pieces on the board, the unnecessary 

obstacle is that each type of piece can only move 

a certain prescribed way, and we attempt to 

overcome this in order to capture the king of our 

opponent. 

One example of gamifying psychotherapy is if we 

posit something similar: Psychotherapy is the 

voluntary attempt to overcome unnecessary 

obstacles. 

Psychotherapy must be voluntary to be 

successful. If the patient refuses to engage in the 

process either by physically or mentally absenting 

himself, therapy will not happen. Yet even people 

mandated to treatment can benefit from it if 

they agree subconsciously to engage with us. 

Adolescents who are dragged to treatment will sit 



with us in stony silence week after week because 

they are not there voluntarily. Sometimes we 

can get a part of them to come out and “play,” i.e. 

engage with us. And if we don’t want to work with 

the patient for some reason, it makes treatment 

next to impossible. 

Patients come to us because they are attempting 

to overcome something. They don’t just drop 

in because they wanted to read the magazines 

in the waiting room. Something in their life has 

caused them pain, sadness, anger, discomfort and 

they want that to stop. They may have noticed a 

pattern of bad relationships, they may be having 

traumatic flashbacks, they may be encopretic. But 

something in their life outside the therapy office 

has seemed insurmountable, and they want our 

help in overcoming it. 

Which brings us to the unnecessary obstacle. I 

would suggest that in many cases the symptom 

is the unnecessary obstacle. Whatever the 

behavior might have been in the past it is no 

longer necessary now. As a child, hiding their 

body or mind may have been necessary to 

keep themselves safe from an abusive parent or 

sibling. As an adult, their tendency to dissociate 

in meetings and avoid success at work is an 

unnecessary obstacle. As a teen a patient may try 

to control an out of control environment in order 

to feel a sense of self. As an adult they may seek 

to control their bodies through disordered eating 

or self-injury for much the same reason. The 

challenge here is that the patient continues to go 

through life unconscious of this and acting as if 

the obstacle was necessary. In a sense they are 

playing out (albeit very seriously and sometimes 

fatally) something outside of the playground. 

Johannes Huizinga in his book Homo Ludens 

referred to the “magic circle” of play, within which 

the game unfolds. Therapy, with its 45-50 minute 

hour, office setting and professional boundaries, 

is such a magic circle. If you don’t take the idea 

of play seriously, you will probably find this 

analogy offensive. But in my opinion, play is very 

serious. In psychotherapy, patient and therapist 

become earnestly engaged in the immediacy of 

what happens. People become ghosts of other 

people, monsters appear, and ancient kingdoms 

rise up from beneath the waves for a day. I believe 

that most people who have been in treatment 

will be able to recall the immersive and powerful 

experiences they have had there, experiences 

which have felt tragic and heroic. Hopefully the 

patient leaves the magic circle having changed, 

the unnecessary obstacle is overcome, and life 

gets better. 

We live, as Freud did, at the threshold between two 

centuries. We live, as Freud did, in a world story 

frequently punctuated by war. I imagine that back 

then things felt as difficult and healing seemed as 

urgent as it does today. People came to Freud then, 

and us now, to help them overcome unnecessary 

obstacles that were ruining their lives. Freud 

benefited from applying the diverse technologies 

of hydraulics, geology and archaeology to 

understand the human condition; and I believe 

that we can benefit from applying ludology and 

game theory to the serious business of therapy. 

Gamification will not be used to “lighten up” 

treatment but rather deepen it. Patients who play 

video games may respond better to leveling up 

than treatment planning, power-ups as opposed 

to coping strategies. Virtual worlds may serve as 



practice for real ones, just as therapy has served as 

practice for other relationships. 

Freud was an Epic Therapist. He researched and 

synthesized what was going on in the art and 

science of his day in order to do better treatment. 

Today’s Epic Therapists will need to do the same, 

and that means having the courage to play with 

technology, games and ideas. Our resistance to 

doing so is an unnecessary obstacle we need to 

overcome, and our success in achieving this will be 

an Epic Win for our patients and our profession. 

ABOUT THE AUTHOR 

Mike Langlois, MSW, LICSW is 

an adjunct faculty member 

of Boston College School for 

Social Work and a Teaching 

Associate in Psychiatry at 

Harvard Medical School. 

He received his B.A. from Connecticut College in 

1991, and his M.S.W from Smith College School for 

Social Work in 1994. He has 15 years of experience 

counseling adults and families. He is the cofounder 

of Sparta Social Networks and creator 

of http://gamertherapist.com . He has a private 

practice in Cambridge, MA. 

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. 

Subscribe Today! 



REEL 

Jean-Anne 

Sutherland 

CULTURE 

Scientology, Psychiatry 

and the Science of 

Documentary Making 

Increasingly academics, social workers and therapists 

are utilizing film in their work. Here in academia, 

it is assumed that multiple forms of media will be 

utilized in the classroom including motion pictures, 

television, the Internet (YouTube videos), popular 

music and documentaries. While in the past these 

media (particularly film) were used as a “substitute,” 

current scholarship offers a pedagogical process for 

working with media in the classroom. That is, these 

days we seldom hear a colleague say “I’m out of town 

tomorrow so I’m having my TA show a movie.” Instead 

we are engaged with film-as-data rather than filmas-time-filler. 

Thus, it is not unusual for an academic 

department to host a small library of films and 

documentaries for classroom use. Which films end up 

in these libraries are a result of intentional selection 

and random, inexplicable surfacing. 

In the classroom, use of documentaries (“docs,” 

as the folk in the film department call them) can 

be paradoxical. On the one hand, the very style 

of documentaries leads many viewers to accept 

the content as “true” and “real.” It looks “true,” after 

all. It looks objective. Like the news. And, well, we 

all know that news media is true, real and objective 

(sarcasm intended). Unlike teaching, with motion 

picture (which, while often taken as factual, most 

recognize as story telling) it’s trickier to remember that 

documentaries have an agenda, a point of view. A 

“good” documentary will withhold declarative images 

and statements. Rather, these let the audience sift 

through “evidence” and come to a conclusion. While 

there is an agenda, there is still a presentation that 

allows for critical thought. Others specifically spell out 

their agenda (think Michael Moore). Others don’t spell 

out their agenda in the least but instead use a variety 

of film techniques to pitch declaratives and absolutes. 

Recently I was perusing our department film library, 

which consists of a handful of popular films but mostly 

documentaries. My eye was drawn to a dark DVD case, 

the cover a macabre image of (U.S.) dollar bills rolled 

up, blood oozing, levitating above the plain, white 

crosses of a graveyard. “What is THIS?” I said aloud, 

snatching it from the shelves. The title, in white letters, 

against a black background, the image of blood 

trailing: “PSYCHIATRY - An Industry of Death” (2006). 

Like many docs, the DVD case proclaimed such things 

as “…lays bare the destruction…,” “Graphic footage…,” 

“interviews with…experts…” I was a bit intrigued. I 

am a sociologist after all. Most of us don’t scare easily 

(at least when it comes to “laying bare” institutional 

practices). As a good social scientist, I checked to see 

who produced such a doc. The DVD case said that 

the producers were “The Citizens Commission on 

Human Rights.” “Well,” my sociologist voice thought, 

“that certainly sounds like a fine organization.” Who 

hates human rights, after all (more sarcasm intended)? 

But, upon further reading, I saw that the CCHR was 



founded in 1969 by the Church of Scientology. Ah, 

that explains it. 

What has not been explained to me is how this 

doc made its way into our collection. Oftentimes 

films are requested by faculty and ordered for 

the department. But in my casual asking-around, 

no one seemed to recall how we acquired this 

one. Again, not THAT unusual. We don’t keep a 

sophisticated record of our DVDs. But, I couldn’t 

imagine anyone actually ordering and showing 

this in class unless the purpose was to demonstrate 

objectivity (specifically: lack thereof) in reporting 

data. 

As I said above, all docs are subjective in that they 

represent the views of the filmmakers. But this one 

seemed to me to cross the line into heavy-laden “I’ll 

do what it takes to scare you into believing me.” Of 

course I watched it. Who would ever comment on 

something without having critically analyzed that 

something? 

I was scared. I was scared by the horror movie 

music, the fleeting, hazy imagery, the spliced, 

erratic voice-overs of newscasts. The images 

come faster and faster until, DONG, there it is: the 

imposing, word in bloody font: “Psychiatry.” 

Many of you will know this DVD all too well. For 

those of you who are not familiar, the video makes 

it attack on psychiatry, linking it to everything from 

school shootings to the Ku Klux Klan. According 

to one “expert,” as far as psychiatry goes, “Nothing, 

nothing is being done that is legitimate.” As 

many critics have noted, the producers take 

tremendous liberty with world history – apparently 

unconcerned with employing a fact-checker. It has 

been critiqued as a form of conspiracy theory on 

steroids. Of course there are some legitimate items 

thrown in: over-medicating is an issue; there were 

some pretty hideous procedures in the 1700’s and; of 

course an ice pick through the eyeball would indeed 

hurt. Thus, a few genuine concerns are tossed in but 

a critical analysis of psychiatry this is not. 

After a bit of digging, I ran across some information 

about the distribution power of the Church of 

Scientology. In a word: OMG (FYI: OMG has recently 

been added to the Oxford English Dictionary thus 

legitimating my use of it). It seems the Scientologists 

have one of the most prestigious distribution centers 

in the world. For a visual, check this out: http://www. 

youtube.com/watch?v=2ujgRFmJjyE. I therefore 

should not be surprised that their DVD made its way 

into our department library. 

Given the proliferation of Scientology’s materials, 

particularly regarding mental health, it might benefit 

some of us to learn more about their argument. W. 

Vaugh McCall (2007) reviewed the writings of L. Ron 

Hubbard. He argues, “The persistent and effective 

campaign of the Church against the practices of 

psychiatry require that all mental health providers 

gain some understanding on the Church 

of Scientology’s beliefs as 

they pertain to mental 

health and psychological 

functioning.” Objectivity, 

after all, implicitly requires 

knowledge of that which we 

critique. And, objectivity is 

science, isn’t it? 

REFERENCE 

McCall, W. Vaughn. 2007. “Psychiatry and Psychology in 

the Writings of L. Ron Hubbard.” Journal of Religion and 

Health, 46:3 437-447. 

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. 



Jason S. Z ack 

Mark-eting 

Yourself 

An interesting consequence of conducting your 

professional work online is that you soon find yourself 

needing to adopt a domain name. Although an online 

counselor might choose something based on his 

or her name, like wendyjones.com or doctorsmith. 

com, many online counselors opt for a more creative 

approach and register domain names that incorporate 

"etherapy" terms (eshrink, cyberpsych, etc.). Of course, 

it's only a matter of time before someone else starts 

using a similar phrase and you start to wonder what 

kind of legal protection you have for your brand. After 

all, your competitor might not be as ethical as you are, 

or your client might be confused and head to someone 

else's website. Then again, you might find yourself 

receiving a threatening letter from someone using a 

similar name demanding that you stop your own use. 

Naturally, we're talking about trademarks here and in 

this column I want to give you some basic information 

on the subject. Note this discussion refers solely to U.S. 

trademarks and is not a complete statement of the law 

of trademarks. 

A trademark is (most typically) a word or logo that 

a purveyor of goods or services uses to identify its 

goods and distinguish them from others. Trademarks 

should not be confused with copyrights, which are the 

exclusive rights afforded to creators of literary, artistic 

and other works to control the reproduction, display 

or performance of their works. Nor should trademarks 

be confused with patents, which are limited-term 

rights granted by the government to inventors for the 

exclusive rights in their novel, non-obvious, and useful 

ideas (when described, reduced to practice, and filed 

publicly in a particular way with the patent office). 

Unlike copyrights and patents which have a limited 

term, trademarks may be enforced indefinitely, so 

long as the mark continues to be used in commerce. 

Trademarks can be strong, and subject to great 

protection from use by others, or weak and entitled 

to less protection, depending on how distinctive the 

marks are. Strong trademarks include arbitrary or 

fanciful marks that have no ordinary connection to the 

services being offered (e.g., Kodak, Amazon, Apple) 

and suggestive marks that imply something about 

the product but don't exactly describe what's being 

offered (e.g., Fresh Direct, Speedy's). Descriptive marks 

(e.g., "Burger Shop" for a hamburger vendor) are weak 

but protectable if they acquire "secondary meaning" 

(i.e., they become associated with a particular source), 

but generic marks (which simply identify the product) 

are unprotectable. A trademark owner may lose the 

right to use the mark if it becomes generic. 

As a general rule, owners of marks that are relatively 

strong or which have acquired secondary meaning can 

prevent others from using the same or substantially 

similar mark on similar goods and services where 

there would be a likelihood of consumer 

confusion upon encountering the junior 

(later) user's mark. Courts apply a variety 

of factors to determine whether there 

is a likelihood of confusion. Owners 

of famous marks can even prevent 

others from using confusingly 

similar marks where there is no 

likelihood of confusion under a 

legal theory called dilution. 

36 36 T IT LI T L T MMA AG GA AZ IZ NI NE E MmA ay y 2 20 01 1 1


Before adopting a trademark for your goods or 

services--probably around the time you are considering 

registering a domain name--you will want to investigate 

http://www.op.nysed.gov/prof/psych/ 

first whether someone else is using a similar mark. 

There's no point in investing in developing an online 

brand only to receive a cease-and-desist letter from a 

senior user. You can do the basic search on your own: 

• See whether the mark and its variants are being 

used as URLs; 

• Use several Internet search engines to see if 

anyone is using your proposed mark; 

• Search for the mark in Trademark Electronic 

Search System (TESS) at the U.S. Patent & 

Trademark Office (USPTO). http://tess2.uspto. 

gov/ 

Once you've decided on a mark that you think is 

unlikely to be confused with another existing mark, you 

may decide to register the mark. Note that you don't 

need to register a trademark with the USPTO to have 

rights in it. All you need to do is use it in commerce 

(exactly what that means is beyond the scope of this 

article). You may choose to let others know you are 

using your name or phrase or logo as a trademark by 

adding the symbol near the mark, but that's not 

strictly necessary. Note that the ® mark indicates that 

the mark has in fact been registered with the USPTO 

and you should not use it unless that is the case. 

Among other benefits, registering the mark puts the 

world on notice that you have rights in the mark 

and puts you in a much better position 

if it ever becomes necessary to file a 

trademark infringement lawsuit. 

You can apply to register your 

mark by yourself, and instructions 

are available at http://www.uspto. 

gov/trademarks/teas/tutorial. 

jsp (as of this writing, the filing fee 

for a trademark/servicemark is $325 

in a given class of goods). However, 

registering can be more complicated than 

LEGAL 

BRIEFS 

it seems and you will be best served by consulting with 

a trademark attorney--which can cost closer to $2,000. 

An attorney can run a formal trademark search, draft a 

description of goods and services that will pass USPTO 

muster and withstand any challenges down the road, 

and just generally help you to navigate the system. 

Finally, once you adopt and (if you choose) register 

a trademark, it's up to you to continue to use the mark 

and to monitor its use in the marketplace. You can lose 

your rights in a mark if you let others use or register 

similar marks without objection. An attorney can help 

you to maintain and enforce your rights. 

Establishing an online identity is an important part 

of connecting with potential clients and making a name 

for yourself on the Internet. A basic understanding of 

trademark law can help you take confident strides as 

you build your online counseling brand. 

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. 

T I L T M A G A Z I N E m a y 2 0 1 1 37


L y l e L a b a r d e e 

D 

TECHNOLOGY ENHANCED 

In my previous column I introduced the term 

“Technology Enhanced Coaching” (TEC), and 

reinforced the idea that the importance of 

establishing what is known as “presence” in 

coaching calls for augmenting the use of 

technology and web enabled applications with 

traditional face-to-face or voice-to-voice support. 

In this column I will present a TEC resource that is 

as much about cutting edge web technology as it 

is about the age old effectiveness of writing and 

sharing personal thoughts with those whom one 

trusts. 

Our featured web application, JournalEngineTM, 

was developed by Kim Ades, MBA and her team at 

FOM Inc. in Toronto. Before we take a closer at it, let’s 

start with a perspective on why a web application 

that supports journaling and the sharing of one’s 

journal entries with trusted members of one’s 

community might be so important to us today. 

Margaret Wheatley, an organizational psychologist 

and teacher, has been organizing conversations 

among people in their local communities in 

over 30 countries. These conversations inspire 

local leaders to act, to achieve breakthroughs in 

understanding, reconciliation, and the formation 

of action steps. In her 2002 book, Turning To One 

Another - Simple Conversations to Restore Hope 

to the Future, Meg writes, 

"For as long as we've been around as humans, 

as wandering bands of nomads or cave dwellers, 

we have sat together and shared experiences. … 

We have never 

wanted to be 

alone. But today, 

we are alone. 

We are more 

fragmented and 

isolated from one 

another than ever 

before. ... As the 

world becomes 

more complex 

and fearful, we 

know we need 

each other to find our way through the darkness. The 

yearning for community is worldwide. What can we 

do to turn to one another?" 

Well, if the skyrocketing number of Facebook users 

(now exceeding 600 million) is any indication, 

what many are doing is turning to the web to share 

and connect with friends. But is today’s Facebook 

experience intimate enough to achieve the kind of 

personal sharing and life changing call-to-action 

that Meg describes? 

Kim doesn’t think so. While recognizing 

the success of Facebook and other social 

media applications such as LinkedIn and 

Twitter relative to enabling people to 

connect, she sees these applications 

falling far short of providing a 

private, intimate place where 

members can interact with a 

close circle of trusted friends 



COACHING 

and associates, and perhaps even a coach, about 

their needs, concerns and interests. 

If Facebook is the lobby, then JournalEngineTM 

might be considered the private table setting 

where a few close associates meet regularly for 

conversation about what matters most. It provides 

users with web enabled resources, connectivity 

to selected friends, and even a coach. It provides 

a place where one may experience the fruit of 

core coaching competencies such as trusting 

relationships, being heard, becoming aware, 

envisioning new possibilities and designing 

actions. More specifically, the “Standard 

Features” list for users includes: Journaling, 

Homework, Courses, Surveys, Import/Export, 

Social Networking, Messaging, Goals, Privacy and 

Search. While all of these features work together, 

the one that finds its place in the name of the 

software, “Journaling” stands out, and Kim sees 

journaling as much more than a writing exercise. 

It is a “blueprint of a person’s history, mindset and 

intentions.” Shared online with one’s coach and 

trusted circle of friends, the journal serves as a kind 

of quilt that all invited parties touch together; it 

reflects the uniqueness of its owner, yet its design 

is also influenced by those invited to 

touch it with their comments. 

And like all enriching 

experiences shared 

with others, it’s the 

relationship with 

others that not only 

instructs, but reinforces, encourages growth and 

invites others to keep coming back together. 

In Meg’s words, 

“The simplest way to begin finding each other again 

is to start talking about what we care about ….we 

need time to sit together, to listen, to worry and 

dream together.” 

Not intended to be used independently of faceto-face 

or voice-to-voice interaction with a 

coach, JournalEngineTM supports, reinforces and 

enhances the coach-client interaction in between 

regularly scheduled visits. We invite you to learn 

more about JournalEngineTM by having your 

own experience with it at the Tap the Potential 

LLC website at http://community.tapthepotential. 

com, or by contacting Sabrina Schleicher, PhD, 

ACC; Community Developer, JournalEngineTM 

Software at 307-856-4662. 

We’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 us know, we 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. 



Cutting Edge 

Technology 

to Aid People 

with Mental 

Health Issues 

BY David Haniff 



Mental Health problems worldwide are 

on the increase, with the World Health 

Organisation (WHO) estimating that 

around 450 million people worldwide will 

suffer from such a problem. Within the United 

Kingdom 1 in 4 people will suffer from a mental 

health problem throughout their lives. Illnesses 

such as depression are even taking over the 

top spot of illnesses worldwide, even looking 

to beat cancer as the most prevalent illness. 

Illnesses such as depression can also have an 

effect on the body leading to health problems 

such as obesity, anorexia and addictions (such 

as alcohol and drugs). There are many mental 

health problems such as phobias (e.g. fear of 

spiders), Attention Deficit Hyperactive Disorder 

(ADHD) (which can be diagnosed in teenagers 

with low attention spans but can also effect 

adults) and Schizophrenia (hearing voices or/and 

seeing non-existent entities). Treatments can 

range to medication (such as anti-depressants, 

for example Prozac, which release Serotonin into 

the brain to help relax it), Cognitive Behavioural 

Therapy (which uses psychological techniques to 

change their way of thinking), counselling and/or 

exercise. 

In conversations with counsellors working 

for leading mental health charities ‘Milton 

Keynes Mind’ and the ‘Milton Keynes Richmond 

Fellowship’ within the UK in certain cases of 

depression it can be the case that the reason why 

they are depressed is because their needs are 

not being met. Due to their low mood they are 

not getting enough sleep and a cycle ensures 

where they are having negative thoughts, 

coupled with a low mood and lack of deep sleep 

they cannot therefore rationalise their situation 

and think positively about their circumstance. 

Relaxation and sleep are therefore crucial to 

thinking clearly about why their mood is low. 

Technology can be used to aid the treatment 

of such conditions, for example, Virtual Reality 

(simulated virtual environments) have been used 

to provide relaxation, by providing pleasurable 

surrounding. Virtual Reality has also been used 

to help treat shyness in males when conversing 

with attractive females, which I can relate to 

when I was teenager. Believe it or not with virtual 

characters such as an attractive female, similar 

physiological responses are present within the 

male such as sweating and pupil dilation. Virtual 

Reality has been used to treat such phobias by 

exposing people to their fear so often that they 

become accustomed their phobia that it no 

longer becomes a problem. 

This exposure therapy has been used to treat 

people with a fear of flying, spiders and even 

storm phobia. There has also been a growth in 

research into the use of Virtual Reality to help 

treat people with Post-Traumatic Stress Disorder 

(PTSD). When some soldiers come back from 

war and back into civilian life they suffer from 

PTSD and can have flashbacks, disturbed sleep 

and hyper-physical arousal (e.g. reaction to loud 

noises). By gradually exposing the soldiers to a 

simulated combat scenario the effects of PTSD 

are reduced as they become accustomed to the 

combat situation. This form of PTSD treatment 

has also been successful in the treatment of 

survivors of 9/11. A female patient suffered 



point of view though, all the studies carried out 

in the US show promise, many of the studies 

themselves are lacking in the number of people 

evaluating the Virtual Reality systems. Computer 

Games have also been used to help treat 

adolescents with mental health problems. 

from a sense of detachment and hyper-physical 

arousal since the tragedy of 9/11, however, 

through exposure therapy she was successfully 

treated. As computers are becoming more and 

more powerful Virtual Reality as an option for 

therapy is becoming viable. Due to the realism 

of the graphics and in some cases the use of 

sound the applications require a great deal of 

computational power. In addition, the cost of 

Virtual reality headsets are also coming down. 

The software development tools, however, needs 

to be more accessible, through their interface 

and their cost. Most of the research concerning 

the use of Virtual Reality to help treat mental 

health problems has been carried out in the 

United States of America, however, through the 

studies that have been carried out so far the 

potential for their use is clear. From a scientific 

The computer games industry is said to be 

worth 10.5 billion dollars worldwide with games 

ranging from war games such as ‘Splinter Cell’ 

to social simulation games like the ‘Populous’. 

The potential for reaching this market through 

therapy is great. Computer games are generally 

fun to play and therefore appeal to teenagers. 

Work in the US has been carried out where 

a game has been developed that teaches 

teenagers in an implicit manner how to deal 

with their problems, such as setting them goals 

to achieve and planning how to achieve those 

goals. By embedding information into the game 

the teenager learns without knowing that they 

are being taught something. Teenagers are also 

less likely to seek treatment from a counsellor 

as they may not see this as a ‘cool’ thing to do, 

but a game is different matter. A game has also 

been developed by employees of NASA to help 

treat children with Attention Deficit Hyperactive 

Disorder (ADHD). The game takes EEG readings 

(electrical activity from the brain) and provides 

feedback on their level of attention throughout 

the game. The use of EEG data was coupled with 

a standard game such Gran Turismo (a driving 

game). The more the child attended to the game 

the faster the car went. So they were rewarded 

for improving their attention levels. The use of 

EEG was originally used by NASA to improve the 

levels of attention of pilots on long journeys, 

however, the researchers could see the potential 

of the technology to help train ADHD sufferers 

minds. 



As mentioned earlier, relaxation is key in treating 

people with depression. We can all become 

stressed out and not able to relax, it may be 

due to work or personal circumstances. An 

Augmented Reality system (superimposing 

graphical information onto real world images) 

can be used to help learn how to relax using 

EEG. For example, an image can be captured on 

your webcam and picture of a person on your 

webcam can be annotated with the name of 

the person shown on your laptop. It’s basically 

superimposing information on a captured image. 

If the patient can learn to relax, they can get 

better sleep and think more clearly about their 

situation reducing the depression. Problems like 

depression can also be tackled through the use 

of games. 

A computer game can be used to help teach 

people with depression what to do if they are 

confronted with certain situation, giving them 

options of actions to take. If the patient follows 

the correct course of action (e.g. go and see their 

GP as opposed to going to the pub!) then they 

are awarded points. In addition problems such as 

Obsessive Compulsive Disorder (OCD) can also be 

addressed by new technology. 

OCD can manifest itself in irrational behaviours 

and routines. We all have our routines like 

getting up at a certain time in the morning, 

however, OCD can result in people washing 

their hands excessively almost to the point of 

their hands becoming raw or hoarding items. By 

using VR a system can be developed to habituate 

them to their problems, for instance, exposing 

them to dirty hands so that they become used to 

not washing their hands so often. There might 



also be therapist intervention where a therapist 

talks through what they are seeing in the virtual 

environment to try and change the way the 

patient thinks. The use of new technology 

therefore has a great deal of potential to help 

therapists treat their patients. The use of new 

technology such as AR and VR also allow the 

patient to learn behaviour in a less formal way. 

Some people who may be averse to seeking 

treatment with a therapist may find technology a 

less intimidating prospect. 

Despite being a form of illness that is growing 

worldwide research into treatments has been 

often neglected as it is an illness that is not 

readily visible. The use new technology can help 

in its treatment as has been shown with the use 

of VR to treat phobias and PTSD. Other new 

technologies such as the mobile phone (which 

are ever becoming more powerful) can be used 

to provide timely information for those that 

suffer from mental health problems (i.e. sending 

automatic alerts to the hospital if they are in 

distress). Technology can therefore be utilised to 

the advantage of people that are ill mentally and 

physically. 

CONCLUSION 

New technology such as Serious Games and 

Virtual Reality are showing promise for the 

treatment of mental health problems. However, 

in order to gain further clinical acceptance 

throughout the world larger scale studies 

are required. The work thus far has indicated 

that semi-realistic graphical environments do 

have a cognitive and physical effect on the 

patient. In addition, new technologies such as 

mobile technology also provide opportunities 

to provide timely information using a discrete 

and ubiquitous technology. The Internet also 

provides an anonymous and accessible way 

to access treatment. Technology does not 

necessarily have to replace contact with experts 

such as Clinical Psychologists and Counsellors 

but can be used as a tool to help treat people 

who are receptive to the use of such new 

technologies. 

About the Author: 

Dr David Haniff has worked as a Researcher at the 

University of Birmingham (UK), Loughborough 

University (UK) and the Open University (UK). He 

has published over 20 publications in Journals and 

International Conferences. In 2009 he founded 

the 'Pervasive Technology Lab (CIC)' (http://www. 

pervasive-technology-lab.org) a non-profit company 

looking into the use of new technology to help 

people with mental health problems. He is based in 

Milton Keynes, UK. 



A Day in the Life of 

an Online Therapist 

A typical day for me involves working both a 

traditional job, and using my after-hours time 

for freelance work. Although it requires a lot of 

organization and flexibility (and coffee), it certainly 

keeps me motivated and engaged. Currently, 

I am working in an interim academic position in 

Rochester, NY while I continue to build experience 

as a distance career counselor. 

Kate Scahill 



Over the past two years, I have been attempting to 

transition out of employment in college settings 

to making a living as an independent counselor. 

The greatest challenge for me has been finding 

the right balance between financial stability, and 

much needed freedom from a 9-5 schedule. After 

a brutal winter in the Northeast and feeling a bit 

out of balance as I juggle two jobs, I am excited for 

spring and the possibility of shifting my focus to 

more independent work and the many rewards it 

provides. 

My initial goal when I began a graduate program 

in Counseling Psychology many years ago was to 

become self-employed. Like many who choose 

the counseling profession, I desired independence 

and a less restrictive work environment. However, 

during my first graduate internship in a small 

women’s college, I was introduced to career 

services, which for me was a new path within 

the counseling profession. I loved the balance of 

working with students, alumni and employers 

while gaining a greater understanding of various 

companies, industries and career paths. It was 

during the dot-com boom of the late nineties, 

and the world of work was changing rapidly. 

Technology was playing an increasing role in 

the job search process, and counselors were 

beginning to understand the need to gain 

technical skills to keep up with the changes. 

The days of mailing resumes were ending, and 

using the web for research and job searching 

was just beginning. I enjoyed learning and 

teaching new technologies to clients, along with 

providing traditional counseling, and found it to 

be appealing combination of techniques. I had no 

idea that someday these skills would be a perfect 

fit for a role as a distance counselor! 

As I continued in my graduate program, the goal 

of a private practice seemed increasingly out of 

reach, as we were told of the many difficulties 

of obtaining licensure, being added to health 

insurance boards, a glut of counselors in certain 

areas, and the uncertainty of a consistent income. 

Thus, over the next 10 years, I continued my work 

in career services. First as a trailing spouse, and 

then for various opportunities, I relocated several 

times. I moved from Boston to Cincinnati, New 

York, New Orleans, Los Angeles and back to the 

East Coast. Since every city has a college, and 

most have career centers, the work was never hard 

to find. I wanted to experience living in various 

places until I found the right fit. Although I am 

still looking for the perfect place for me, I have at 

least narrowed my search and learned a great deal 

in the process. 

Through my many moves, I gained vast skills 

and knowledge of career counseling students 

of all degrees and disciplines, and working with 

employers on recruiting and finding the best-fit 

candidates. I have counseled MBA candidates, 

engineering students, nontraditional and liberal 

arts students and many who are undecided or in 

career shifts. I interfaced with recruiters in industries 

including investment banking, accounting, 

marketing, non-profit, entertainment and 

everything in between. Because I worked closely 

with employers, I gained a great deal of insight 

into interviewing and hiring practices, which I can 

share with my clients. As my last position as an 

interim Employer Relations manager at UCLA was 

coming to a close, I discovered ReadyMinds and 

contacted them immediately. The opportunity to 

work as a career advisor over the phone and via 

email seemed like a perfect fit for my background 

and interests. After an in-person training and 

a Distance Counselor Certification, I began my 

career as a ReadyMinds Career Counselor. 



Now, in addition to my job in academia, I am in 

independent contractor providing career services 

to students in all phases of their career. The work 

is conducted over the phone and by email, but to 

me is no different than in-person counseling. We 

can cover all of the same topics as we would in 

an office setting, with the added benefit of being 

able to quickly direct the client to resources online. 

Plus, I am easy to contact via email should the 

client have questions between or after sessions. 

Distance counseling for many clients is not only 

preferable, it is the only way they are able to get 

services that fit into their schedules. 

My clients are all over the United States, Canada, 

and occasionally other countries. This encourages 

me to learn about the cultures and opportunities 

of other cities in order to guide my clients. My 

frequent moves also help me understand the 

challenges and opportunities my clients face 

when deciding on possible relocation. I am thrilled 

to be able to use my technical skills, counseling 

abilities and draw on my personal experiences to 

provide solution-focused career services. Distance 

counseling has afforded me to the opportunity 

to continue to be geographically flexible, as I am 

able to take the work with me wherever I go; I just 

have to figure out where that will be! 

About the authoR: Kathryn Scahill, NCC, DCC, is a 

ReadyMinds Counselor and Trainer. In her roles, she now 

trains other colleagues in the distance field while staying 

up to date on a daily basis delivering distance services 

herself to students on a national level. She is also currently 

a Counselor and Advisor to students at the Rochester 

Institute of Technology. She is based in Rochester, New 

York, USA. 



an Online 

A Day in the Life of 

Our family-owned weight loss business has been serving the community 

for almost 30 years. I joined the business in 2001 after spending 

much of 2000 losing 57 lbs. on this very program----and, of course, my 

mother was harder on me than she was on any other client. I came to 

see in 2002, as was the pattern all those years before, that during certain 

times of the year clients would put their programs on ‘hold’ to accommodate 

stretches of time when they wouldn’t be able to come in 

for their multiple private visits per week. 



Lori Boxer 

Coach 

Snowbirds that spent their 

winters in Florida, those who 

were away at summer homes, 

kids at sleep-away camps, 

college students living on 

campuses—all would put 

their progress on the back 

burner until they returned 

home. How silly was that?! So 

many clients would convince 

themselves that after weeks 

or months of private, one-onone, 

individualized in-office 

counseling, including personal 

meal planning, and all the 

other services we provide, 

they’d somehow be able to 

go from that mode to an ontheir-own 

mode with the same 

discipline and structure and 

be accountable to themselves! 

Naturally, what could happen 

did in most cases. Most clients 

returned after a long absence 

having gained much of the 

weight they had lost. 

The next summer was a testing 

ground, so to speak, for using 

technology to NOT let distance 

get between us and our clients. 

We started with those 

clients who spent 

their summers away 

from home. Yes, we 

knew they wouldn’t be 

perfect. Yes, we knew 

they didn’t want to 

be perfect … summer 

brings longer daylight, 

more time outside 

and away from the 

more controlled environment 

of one’s kitchen and one’s 

own cooking. But, we also 

knew that to go away for the 

summer with SOME discipline 

and accountability would be 

better than none, and if clients 

would come back at the end 

of the summer being the same 

weight as when they left, well 

… THAT would be a great point 

from which to pick up when 

they came home. 

We put forth the idea to these 

clients to work with us longdistance 

during the summer, 

and they loved it. We asked 

them to have access to a 

bathroom scale; to call in (or 

email) twice a week on preset 

days with their morning 

weights; we asked them to 

either email or fax their food 

diaries at least once a week; 

and we scheduled 10-15 

minute phone conversations 

with them twice a week; and, 

as always, clients have 24/7 cell 

phone access to me for those 

“I’m about to lose it’ moments! 

In this way, we stayed on top 

of them, they knew they were 

accountable, they stayed 

more focused while away from 

their home environments, 

and, most importantly, they 

felt good about themselves 

because, as they told us, they 

were continuing to ‘work’ on 

themselves and that alone 

meant they were moving 

forward. How wonderful it was 

for clients to return after the 

summer, having either stayed 

virtually the same weight or 

even losing a few pounds. This 

was important because after 

the summer, the fall feeding 

frenzy of the holidays wasn’t far 

behind! To come home with a 

10 or 15 pound weight gain so 

close to the difficult challenges 

the holidays bring, is to make 

the re-start that much more 

difficult. 

Well, the rest is history. That 

winter, we serviced our 

snowbirds as well as all the kids 

going off to college in the same 

manner we did with our clients 

in the summer. Slowly, through 

word-of-mouth referrals from 

these clients and others, we 

received inquiries from across 

the country; and most recently 

started working with a client in 

London. The advent of Skype 

technology allows us to offer 

that type of interface as well. 

Whether we're seeing clients 

in person or over the phone, 



our days begin at 8:30 or 9:00 

a.m. and end at about 7:00 or 

8:00 p.m. three business days a 

week. For those phone clients 

where a different time zone 

might apply (i.e., London), 

it is a client's responsibility 

to schedule with us during 

our normal business hours; 

although we will of course 

accommodate an extenuating 

circumstance by having one 

of my staff go to the servicing 

office as early as 7am. Working 

with clients by telephone is 

done only in the offices; I am 

the only one in the business 

who is accessible to clients 

24/7 via my home and cell 

numbers. Between the faceto-face 

meetings, scheduled 

(and oftentimes unscheduled) 

phone conversations, 

communications via email 

(there is always a long, long 

queue waiting for me when I 

get home), I would say I devote 

at least 80 hours a week to my 

business. 

Regardless of the habit we 

want to change, the addiction 

we want to break, the goal 

Lori Boxer is the Director of 

Weight*No*More Diet Center 

with offices in New York and 

New Jersey. Visit them at www. 

weightnomoredietcenter. 

com and www.facebook.com/ 

WeightNoMoreDC. 

we want to reach, we all 

need a partner … to push 

us from behind, to pull us 

from the front, to who we 

are accountable. We are that 

partner to our clients, and 

technology helps us to help 

them. 





Cyber 

Supervision 

Anne Stokes 

Readers are probably familiar 

with the Cyclical Model for 

face-to-face supervision. In this 

article, after first outlining the 

model, I'm going to show how 

it can work online. This is not 

'the truth' - simply one version 

of how it might happen on one 

day. 

The model has 5 stages, each 

with five sub-divisions (not all 

of which need to be present 

each time) giving a framework 

to the supervision process. It 

is a map, and is flexible, not 

a rigid structure. In my next 

column, the third stage will be 

demonstrated, using material 

from a live IM session. 

uContract: the overall 

agreement for supervision 

and also the agreement for 

that session. Its five divisions 

encompass ground rules, 

boundaries, accountability, 

expectations and relationship. 

vFocus: the point of entry 

into the 'work' - the locus of 

attention. The sub-divisions 

here are: issue, objectives, 

presentation, approach, 

priorities. 

wSpace: sometimes termed 

'creative play space', this is the 

heart of supervision. It's about 

exploration, experimentation, 

reflection, insight and 

understanding. The five subdivisions 

are: collaboration, 

investigation, challenge, 

containment, affirmation. 

Online supervisors need to 

think about (and practice) ways 

to encourage creativity in this 

medium. 

xBridge: this is what it 

sounds like - the bridge back 

from the supervision process 

into the counsellor's work. 

Consolidation, information 

giving, goal setting, action 

taking, and client's perspective 

are the five sub-divisions. 

yReview: this last stage is 

both a continuous process 

and periodic major review. 

Routinely, in each session, 

there’s a review of what’s been 

achieved and what needs to 

be carried forward. The subdivisions 

here are: feedback, 

grounding, evaluation, 

assessment, re-contracting. 

• • • • • • 

So, here is an example of an 

online session. 

jAdele has come to an online 

chat supervision session 

with Lisa, and in the first few 

minutes of the session they 



Using the Page and Wosket 

(2001) Cyclical Model of 

Supervision Online (Part One) 

contract for that session. Adele 

states that today she would 

like to bring two clients and 

asks Lisa to be the one to 

watch how time is allocated 

during the session to leave her 

free to think about her clients 

(groundrules/ expectations). 

She also tells Lisa that she has 

signed up for a short course on 

Solution Focused Behavioural 

Therapy (SFBT), as in the last 

session they had discussed the 

fact that she was beginning to 

take EAP clients without having 

any training to work short term 

(boundaries/accountability). 

Lisa asks whether there was 

anything they needed to come 

back to from that session as 

she had wondered if she had 

appeared rather authoritarian 

at one point (relationship). 

kAdele presents her first 

online client, outlining the 

issues as she sees them, and 

says that she wants to have a 

clearer sense of how her client 

relates to people (objective 

and possibly priority). She says 

how they have been working 

together (approach) and 

recognises that the priority is 

about how she and the client 

relate. 

l In the space, Lisa asks 

Adele if she has an image of 

the relationship. She comes 

up with a metaphor which 

they expand and explore 

together (collaboration and 

investigation). Lisa facilitates 

Adele as she works with anger 

she feels towards her client 

(containment), notices that this 

has been a theme with several 

clients recently (challenge), 

and affirms Adele's awareness 

that this is something she may 

need to explore further in her 

own therapy as well as here in 

supervision. 

mAdele then thinks about the 

insights into her relationship 

with this client (consolidation) 

and Lisa asks if she knows 

about an article which might 

also be useful in thinking 

about it (information giving). 

Adele decides that she does 

not want to set any goals or 

plan any action with this client. 

Lisa asks if she has any sense 

of what the client might say if 

she heard Adele decide that 

no action was needed. Adele 

is comfortable that she would 

agree (client perspective). 

kThey return to focusing 

on the second face-to-face 

client, with Adele outlining 



the priority as being how to 

address the client's difficulties 

in regularly attending sessions. 

She tells Lisa what she has 

done already in this area 

(approach). 

l In the space, Adele decides 

to 'become' the client and asks 

Lisa to be her - addressing the 

issue with her-as-client. Adele 

experiences huge ambivalence 

towards Lisa as counsellor, and 

they explore what might be 

happening both in the 'here 

and now' and also in the 'there 

and then'. 

m This has helped Adele to 

have a greater understanding 

of what might be going on for 

her client (client perspective) 

and some sense of how she 

might take this forward (goals 

and action). 

n As they come towards 

the end of the session, Lisa 

feeds back to Adele that she 

has noticed she is gaining 

confidence in experimenting 

online, and Adele agrees that 

she now feels able to risk 

trying things out. They are 

both quiet, not typing for a few 

moments, reflecting on the 

session (grounding) and then, 

as always, they look at what’s 

been useful and what they 

might have done differently 

in the session (evaluation). 

Adele tells Lisa that as part of 

her appraisal in the agency 

where she works online, there 

has been a suggestion that 

supervisors should be asked 

for a report (assessment) and 

suggests they spend some time 

in the next session discussing 

this (re-contracting). After 

checking details of the next 

session, they end. 

• • • • • • 

In the next issue of TILT, I will be 

showing how the third stage 

– the space – has been used 

extremely effectively in reality. 

Reference: 

Page, S., and Woskett, V. (2001) 

Supervising the Counsellor: 

a cyclical model, 2nd edition. 

London Routledge 

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. 

FOLLOW 

TILT MAGAZINE 

on Facebook and Twitter 





NewInnovations 

Money Matters: the 

State of Online Therapy 

Reimbursement in 

the United States 

Mark Goldenson 

When bank robber Willie Sutton 

was asked why he robbed banks, 

he famously said, “that’s where 

the money is.” In health care, 

the money is in reimbursement. 

SAMHSA reported that in 2003, 

Americans received $121 billion 

in mental health and substance 

abuse care. Public payers – 

Medicare, Medicaid, and state 

and federal sources - covered 

61% ($74 billion) of these costs. 

Private payers covered 26% 

($31 billion). Only 13% ($16 

billion) of costs were paid outof-pocket. 

The unfortunate reality in 

American health care is that 

new services are driven 

primarily by reimbursement. 

In telemedicine, previously 

major barriers – expensive 



technology, 

licensing 

regulations, provider and payer 

skepticism – are falling. Now 

the number one issue to resolve 

is reimbursement. 

The good news is that reimbursement 

is growing significantly. 

The first CPT code for 

online therapy was issued in 

2004, but now CMS has dozens 

of codes to reimburse telemental 

health. The American Psychological 

Association recently 

published an excellent update 

on reimbursement. 

Key findings include: 

ff 

Medicare reimburses 

telehealth on par with faceto-face, 

but services must be 

done via real-time audio-video 

and requires that the patient 

be at a health facility in a 

Health Professional Shortage 

Area or outside a Metropolitan 

Statistical Area – basically a rural 

area – though a bill introduced 

last month by Senator John 

Thune would allow Medicare to 

reimburse home health services 

ff 

Medicaid reimbursement 

is decided by the states, 

and at least thirteen state 

Medicaid programs reimburse 

psychologists 

ff 

Private sector payers are 

required by law to reimburse 

telehealth in twelve states: 

California, Colorado, Georgia, 

Hawaii, Kentucky, Louisiana, 

Maine, New Hampshire, 

Oklahoma, Oregon, Texas, and 

Virginia 

ff 

A Michigan State 

University survey found that 130 

private payers are reimbursing 

telehealth, with Blue Cross/Blue 

Shield being a leader 

These are huge developments 

for online therapy. From my 

conversations with executives 

at several major payers, each 

one is either reimbursing 

today or considering how they 

will reimburse soon. Some 

are running internal pilots to 

measure effectiveness, cost 

reduction, and patient and 

provider satisfaction. 

Private payers are also under 

pressure to comply with two 

new laws: the Mental Health 

Parity Act and the new health 

care reform bill. The latter now 

CMS-approved procedures for telemental health 

Centers for Medicaid and Medicare Services 

procedure 

cpt code 

Consultations 99241 - 99275 

Office or other outpatient visits 99201 - 99215 

Individual psychotherapy 90804 - 90809 

Pharmacologic management 90862 

Psychiatric diagnostic interview exam 90801 

Neurobehavioral status exam 96116 



NewInnovations 

requires free screenings for alcohol 

misuse, depression, and tobacco 

use. With forty million new patients 

soon gaining health insurance, 

payers must 

find affordable 

ways to fund 

care and the 

internet will be 

a compelling 

option. 

Mark Goldenson 

is CEO of 

Breakthrough.com, 

a free virtual 

office for online 

counseling. 

Editor’s Note 

Not all mental health disciplines have equitable reimbursement privileges. For instance some insurance 

programs only allow psychiatrists to bill under certain approved telemental health codes such as 

90806. In addition, not all insurance companies recognize the 90804-8 codes as appropriate telemental 

health codes because the codes specifically describe the services as having occurred “in office.” Be sure 

to check with the insurance company before billing with a code that infers an in-person encounter, 

otherwise the billing may be viewed as fraudulent by some companies. Modifiers of these codes are 

available so be sure to bill utilizing the correct modifier (GT for synchronous audio/video and GQ for 

asynchronous telecommunication such as reviewing a previously recorded interview). Be clear about 

how you delivered therapeutic services. Most government and 3rd party insurance will not currently 

reimburse for GT services. 

Additional Resources 

http://www.tmhguide.org/site/epage/93990_871.htm 

http://www.mdcbh.org/images/startupmemo10272010.pdf 

http://www.americantelemed.org/files/public/policy/Medicare_Payment_Of_Services.pdf 


P.O. Box 19265 

Springfield, IL 62794-9265 

BOOK SAVINGS 

(on separate titles only)* 

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

Save 20% on 3 Books ! 

COMING SOON! 

• Douglass, Donna—SELF-ESTEEM, 

RECOVERY AND THE PERFORM- 

ING ARTS: A Textbook and Guide 

for Mental Health Practitioners, Educators 

and Students. '11, 232 pp. (7 x 

10), 6 il., 5 tables. 

• Goodman, Karen D.—MUSIC THER- 

APY EDUCATION AND TRAINING: 

From Theory to Practice. '11, 296 pp. 

(7 x 10), 3 tables. 

• Bernet, William—PARENTAL AL- 

IENATION, DSM-5, AND ICD-11. 

'10, 264 pp. (7 x 10), 15 il., 4 tables, 

$63.95, hard, $43.95, paper. 

• Ensminger, John J.—SERVICE AND 

THERAPY DOGS IN AMERICAN 

SOCIETY: Science, Law and the Evolution 

of Canine Caregivers. '10, 340 

pp. (7 x 10), 25 il., 1 table, $69.95, hard, 

$47.95, paper. 

NOW AVAILABLE! 

easy ways 

5to order! 

• Anthony, Kate, DeeAnna 

Merz Nagel & Stephen 

Goss —THE USE OF 

TECHNOLOGY IN MEN- 

TAL HEALTH: Applications, 

Ethics and Practice. 

'10, 354 pp. (7 x 10), 6 il., 5 

tables, $74.95, hard, $49.95, 

paper. 

• Bellini, James L. & Phillip 

D. Rumrill, Jr.—RE- 

SEARCH IN REHABIL- 

ITATION COUNSEL- 

ING: A Guide to Design, 

Methodology, and Utilization. 

(2nd Ed.) '09, 320 

pp. (7 x 10) 3 il., 5 tables, 

$66.95, hard, $46.95, paper. 

PHONE: 

1-800-258-8980 

or (217) 789-8980 

FA X 

• Bryan, Willie V.—THE 

PROFESSIONAL HELP- 

ER: The Fundamentals of 

Being a Helping Professional. 

'09, 220 pp. (7 x 

10), $51.95, hard, $31.95, 

paper. 

• Correia, Kevin M.—A 

H A N D B O O K F O R 

CORRECTIONAL PSY- 

CHOLOGISTS: Guidance 

for the Prison Practitioner. 

(2nd Ed.) '09, 202 

pp. (7 x 10), 3 tables, 

$54.95, hard, $34.95, paper. 

• Kocsis, Richard N.—AP- 

PLIED CRIMINAL PSY- 

CHOLOGY: A Guide to 

Forensic Behavioral Sciences. 

'09, 306 pp. (7 x 10), 

4 il., 2 tables, $65.95, hard, 

$45.95, paper. 

• McNiff, Shaun—INTE- 

GRATING THE ARTS 

IN THERAPY: History, 

Theory, and Practice. '09, 

280 pp. (7 x 10), 60 il., 

$59.95, hard, $39.95, paper. 

• Richard, Michael A., 

William G. Emener, & 

William S. Hutchison, Jr.— 

EMPLOYEE ASSIS- 

TANCE PROGRAMS: 

Wellness/Enhancement 

Programming. (4th Ed.) 

'09, 428 pp. (8 x 10), 8 il., 1 

table, $79.95, hard, $57.95, 

paper. 

• Thompson, Richard H.— 

THE HANDBOOK OF 

CHILD LIFE: A Guide 

for Pediatric Psychosocial 

Care. '09, 378 pp. (7 x 10), 

5 il., 15 tables, $79.95, 

hard, $55.95, paper. 

• Wilkes, Jane K.—THE 

ROLE OF COMPANION 

ANIMALS IN COUN- 

SELING AND PSYCHO- 

LOGY: Discovering Their 

Use in the Therapeutic 

Process. '09, 168 pp. (7 x 

10), 2 tables, $29.95, paper. 

FAX: 

(217) 789-9130 

EMAIL: 

books@ccthomas.com 

Web: 

www.ccthomas.com 

• Marvasti, Jamshid A.— 

PSYCHO-POLITICAL 

ASPECTS OF SUICIDE 

WARRIORS,TERROR- 

ISM AND MARTYR- 

DOM: A Critical View 

from “Both Sides” in Regard 

to Cause and Cure. 

'08, 374 pp. (7 x 10), 

$73.95, hard, $53.95, paper. 

• Moon, Bruce L.—INTRO- 

D U C T I O N T O A RT 

THERAPY: Faith in the 

Product. (2nd Ed.) '08, 

226 pp. (7 x 10), 20 il., 

$53.95, hard, $33.95, paper. 

• Wiseman, Dennis G.— 

THE AMERICAN FAMI- 

LY: Understanding its 

Changing Dynamics and 

Place in Society. '08, 172 

pp. (7 x 10), 4 tables, $31.95, 

paper. 

• France, Kenneth—CRISIS 

INTERVENTION: A 

Handbook of Immediate 

Person-to-Person Help. 

(5th Ed.) '07, 320 pp. (7 x 

10), 3 il., $65.95, hard, 

$45.95, paper. 

• Martin, E. Davis, Jr.— 

P R I N C I P L E S A N D 

PRACTICES OF CASE 

MANAGEMENT IN RE- 

HABILITATION COUN- 

SELING. (2nd Ed.) '07, 

380 pp. (7 x 10), 7 i1., 2 

tables, $69.95, hard, $49.95, 

paper. 

• Perticone, Eugene X.— 

THE ART OF BEING 

BETTER: An Approach 

to Personal Growth. '07, 

268 pp. (7 x 10), $58.95, 

hard, $38.95, paper. 

• Palmo, Artis, J., William J. 

We i k e l & D a v i d P. 

B o r s o s — F O U N D A - 

TIONS OF MENTAL 

HEALTH COUNSEL- 

ING. (3rd Ed.) '06, 468 pp. 

(7 x 10), 5 il., 3 tables, 

$85.95, hard, $61.95, paper. 

MAIL: 

Charles C Thomas • 

Publisher, Ltd. 

P.O. Box 19265 

Springfield, IL 62794-9265 

Complete catalog available at www.ccthomas.com or email books@ccthomas.com 

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

*Savings include all titles shown here and on our web site. For a limited time only. 

When ordering, please refer to promotional code TILT1110 to receive your discount.


Marketing Toolbox 

Susan Giurleo 

How to Leverage 

Twitter for Online 

Marketing 

You probably know Twitter is a microblog that 

allows you 140 characters to communicate. Initially, 

this doesn’t seem like enough words to 

communicate a full thought, never mind share 

important mental health care information. But 

if you know a few strategies 

to leverage the power of Twitter, 

it can be a wonderful tool 

to market your services, products 

and programs. Here are a 

few ways I’ve been using Twitter 

to grow my business: 

Have a plan. 

1 

Whether you want 

to reach potential 

clients, customers, or colleagues 

it’s important to 

know why you are on Twitter. 

Just like a more traditional 

marketing approach, you 

need to know who you are 

trying to connect with and what message you 

want them to hear from you. 

Be human and professional. 

2 

No one builds relationships with a logo 

or a brand. Use your face as your Twitter 

avatar. People want to see who they are conversing 

with. Also, have a human bio that you write 

in the first person explaining a bit 

about who you are and what you 

do. If you’re comfortable, share a 

piece of personal information on 

your bio that gives people some 

insight into your personality. 

3 

Listen. 

When I started using 

Twitter years ago, I spent 

a lot of time watching and listening 

before I ever tweeted my own 

words. You can listen by following 

people you know and respect, using 

Search.Twitter.com and type 

in a keyword that interests you 

(this could be your hometown, 

a treatment word, such as ‘depression,’ or some 

other interest of yours like ‘gardening.’) When you 

see who’s talking about what, you can decide 



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. 

who to follow to grow your network. You can also 

get a good sense of what that particular community 

is interested in and tailor your business offerings 

and marketing plan accordingly. 

Use Twitter to educate, share, 

4 

teach and inspire. 

Twitter is at its best when we use it to 

share information that is useful to our 

followers. You can tweet a link to an article, research 

paper, or a resource that might be of interest 

to your followers. Be generous with retweeting 

(RT) other’s information. It is fine to share 

your own information but that should not be the 

bulk of what you share. 

Engage in conversations. 

5 

Twitter is social. People converse with 

each other. Conversations can range 

from, “I like your information. Thanks 

for sharing,” to more involved reciprocal conversations 

about a piece of research or current event. 

I converse most often with colleagues and have 

very rarely chatted with clients (past or present). 

One caveat is that therapists should not discuss 

any treatment related issues in Twitter, whether 

or not the client’s identity is removed. 

Take the conversation off 

6 

Twitter. 

When I establish a positive relationship 

with someone via Twitter, at some point one of us 

moves it off of Twitter and into a more private fo- 

rum. Sometimes this is via a direct message (DM), 

email or a phone call. This is how working relationships 

are established, whether with clients or colleagues. 

Always allow a potential client to reach 

out to you first. They may ask “How can I schedule 

an appointment,” and you can refer them to 

your website, email or direct message them your 

phone number. It’s not ethical to approach potential 

clients uninvited. 

Twitter is a wonderful networking tool when you 

have a sense of how to use it efficiently. Remember 

that people use social media to connect and 

find information. When you are a source of useful 

information and take the time to join into the conversation 

people are more likely to want to work 

with you. 



Online Therapy Institute Verification 

When you see this seal on a website it means Online 

Therapy Institute has verified this website as compliant 

with Online Therapy Institute’s Ethical Standards. We 

will display thumbnails of everyone who has become 

verified since the last issue. 



Introducing 

Get Verified 

for Coaches! 

Monthly 

Office Hour 

Events are 

Free 

to Attend! 

Open Office Hours 

We offer two hours each 

month for people to drop 

in and ask questions! 

OTI Chat Room 

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

OTI Conference Centre 

in Second Life! 

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

Upcoming Dates 

Tuesday, june 13, 2011 

> SECOND LIFE 9:00 PM EST 

> CHAT 3:00 AM EST 

July 14, 2011 

> SECOND LIFE 1:00 PM EST 

> CHAT 6:00 PM EST 

August 4, 2011 

> SECOND LIFE 10:00 AM EST 

> CHAT 2:00 PM EST 



“You can never get a cup of tea large enough or 

a book long enough to suit me” 

~C.S. Lewis 

Love 

For the 

of 

Books 


Cyberpl@y: Communicating Online 

Brenda Danet (2001) 

This book explores playfulness and artfulness in digital writing 

and communication and answers penetrating questions about 

this new medium. Under what conditions do old letter writing 

norms continue to be important, even in email? Digital greetings 

are changing the way we celebrate special occasions and public 

holidays, but will they take the place of paper postcards and 

greeting cards? The author also looks at how artforms, such as 

virtual theatre, ASCII art, and digital folk art on IRC are flourishing, 

and how many people collect and display digital fonts on websites, 

or even design their own. Intended as a “time line” documenting 

developments online in the mid to late 1990’s, when the Internet 

became a mass medium, this book treats the computer as an expressive 

instrument fostering new forms of creativity and popular culture. 

BUY NOW 

Infinite Reality 

Jim Blascovich and Jeremy Bailenson (2011) 

The coming explosion of immersive digital technology, combined 

with recent progress in unlocking how the mind works, will soon 

revolutionize our lives in ways only science fiction has imagined. 

In Infinite Reality, Jeremy Bailenson (Stanford University) and Jim 

Blascovich (University of California, Santa Barbara)—two of virtual 

reality's pioneering authorities whose pathbreaking research has 

mapped how our brain behaves in digital worlds—take us on a 

mind-bending journey through the virtual universe. 

Infinite Reality explores what emerging computer technologies 

and their radical applications will mean for the future of human life and 

society. Along the way, Bailenson and Blascovich examine the timeless 

philosophical questions of the self and "reality" that arise through the 

BUY NOW 

digital experience; explain how virtual reality's latest and future forms— 

including immersive video games and social-networking sites—will soon be seamlessly integrated 

into our lives; show the many surprising practical applications of virtual reality, from education and 

medicine to sex and warfare; and probe further-off possibilities like "total personality downloads" 

that would allow your great-great-grandchildren to have a conversation with "you" a century or 

more after your death. 

Visit the Online Therapy Institute’s Book Store to purchase featured books and more! 

http://www.onlinetherapyinstitute.com/bookstore/

c y b e r m a r k e t 

ONLINE NONCREDIT CERTIFICATE 

 

 

Workforce Career Coach Facilitator 

120-hour online program 

prepares you to help others 

find jobs and new careers 

Satisfies training requirement 

for Global Career Development 

Facilitator (GCDF) credential 

Students earn up to 15 CEUs 

EXCLUSIVELY FOR ADULTS 

www.tesc.edu/noncredit 

(888) 442-8372 

Expandyourpractice Improveclientaccess 

ReduceNo‐Shows 

ConnecttoclientsviawebbasedHIPAA‐compliantvideo,email&chat 

Noexpensiveequipmentorsoftwaretobuy 

Collectpaymentsonlineandsubmitclaims 

Privatelabelyourpractice 

Forinformationorafreedemocall616‐805‐9452oremailsales@breakthrough.com 

Online Counseling: 

A Handbook for Mental Health 

Professionals, Second Edition 

Edited By Ron Kraus, George Stricker & Cedric Speyer 

The fully updated new edition is now available! 

Order directly at 

elsevierdirect.com/9780123785961 

Interested in advertising in the TILT Magazine CYBERMARKET? 

20110032_A_Online Counseling ad_095-953_1200.indd 1 3/4/11 11:44 

$75 single issue 

For payment and other advertising options please visit us online at 

http://www.onlinetherapymagazine.com/advertising-options

YOUR AD HERE 

YOUR AD HERE 

YOUR AD HERE 

YOUR AD HERE 

YOUR AD HERE 

YOUR AD HERE 

YOUR AD HERE 

c y b e r m a r k e t

Online Therapy Institute, Inc. 

P.O. Box 392 

Highlands, NJ 07732 

877.773 5591 

www.OnlineTherapyMagazine.com 

Magazine Designed by AI Virtual Solutions 

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

Saving the Game The Use of Gaming within Psychotherapy

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?