Heroes

 

Extra Life Boo & Wow

This post is more personal than some, but then at some time in many of our lives cancer gets personal.  As many of you know, I have a companion and co-therapist named Boo.  For the past 12 years Miss Boo has worked with me to help in therapy.  We have worked with hundreds of children, adolescents and adults in settings ranging from special needs classrooms, alternative schools and outpatient settings.  And for the past decade we have been working together in my private practice.

This past Spring Boo developed a form of cancer known as osteosarcoma, which is a form of cancer where the tumor grows in the bone.  In her case, Boo began limping and we discovered that she had it in her front right leg.  What followed was a series of scary tests and decisions.  The recommended treatment for this in dogs is amputation of the limb and a course of chemo.  I was worried about this on so many levels:  I didn’t want to lose my friend, I didn’t want her to be in pain, and how was I doing to explain this to my patients?  You can’t just have a dog show up one week with one less leg and be all blank screen about it.  Some people suggested I retire her, but so many people come to me with ruptures in attachment, people who just walked out on them or were taken from them, that that didn’t make sense either.  Nope, we were going to do this honestly and mindfully.  If Boo could show up for such a challenging treatment, I could show up for her and we could show up for our patients.

Over the next few weeks I let people know what was going on if they wanted to know, to the extent they wanted to know.  While she was recovering from surgery I let people know that as well.  And when Boo came back to work, well that was a powerful week.  Cancer changes your body, but the self persists.  Boo had a visible change, there was a scar.  Some people approached petting her, some didn’t.  Boo accepted all of them.  Some people were reluctant to talk at first, imagining their problems were nothing compared to cancer or losing a leg, but we explored and put those concerns in perspective.  We all had work to do, and we did it.

Time passed, and chemo ended.  This is the result:

Each year, I take part in Extra Life, a worldwide celebration of the social impact of gamers of all kinds from video games to board games and tabletop RPG’s! Since 2010, Extra Life has raised more than $14 million to help children’s hospitals provide critical treatments and healthcare services, pediatric medical equipment, research and charitible care.  Your donation is tax-deductible and ALL PROCEEDS go to help kids nationwide and locally at my awesome colleagues at Boston Children’s Hospital.

This year, on November 7th, I’ll be playing World of Warcraft with a special avatar in honor of Boo.  (Of course I’ll be taking breaks every 45 minutes to keep my health ans stamina in good shape.)  If you want to join our team, Miss Boo’s Battalion, you can do that too!*  You don’t have to play WoW, you can play Minecraft, Dark Souls, Candy Crush, my colleague Jane McGonigal’s Superbetter, Zombies Run!, anything.  You can play Tabletop games like D&D or Pathfinder.  You don’t have to go 24 hours straight, any amount of time, anything you raise, helps.  Sharing the post helps too–you never know who might decide to donate or get their game on.

Miss Boo is my hero, and if you are living with cancer in your life you are my hero too.  Whether you are battling it yourself, defeating it, thriving after it, supporting someone who is, celebrating a win or grieving a loss, you are a hero.  On Saturday, November 7th, why not be a hero too?

*Past and present patients are asked to refrain to protect their privacy, but can always get involved with Extra Life on their own here.

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Better Living Through Minecraft

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Last month I had the opportunity to talk at SXSW 2015 about how the video game Minecraft has a lot to teach us about mindfulness.  Video games often get a bad rap with mental health folks, but I try to change that thinking by pointing out that playing video games can actually be a form of concentration meditation, albeit one that does not jibe with many people’s traditional concepts of such (focus on your breathing, focus on the candle, focus on..erm, Mario?)  If you want to hear more, the Audio is here:

https://soundcloud.com/michael-langlois-6/better-living-through-minecraft-audio-version

If you want to see the visuals from the Prezi, feel free to do so here:

If you enjoy it, please feel free to share, and if you want me to come talk to you and your colleagues drop me a note.

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The Lava Expert

lava cave

“Sometimes it is the people no one imagines anything of who do the things that no one can imagine.”  –The Imitation Game

Shortly before I fell into the lava I began a conversation with an eleven year old girl, we’ll call her Sal.  This was a while back, on a Minecraft server I play on from time to time.  My name when I play Minecraft has the word “therapist” in it, and Sal had noticed this.

“Hey, are you really a therapist?” Sal asked via our server text chat.

“Yes I am.”  I typed back.  I had been mining obsidian and using a river to cool the lava so I could chip away at it with my diamond pickaxe.  In the time it took to type my reply, I managed to fall into the river and get washed into the lava.  I watched myself go up in flames, and with me most of my loot.  There is always a chance though, when one falls into lava this way, that some of one’s loot can be thrown clear.  So upon respawning I quickly made my way back to the scene of my demise as we continued our conversation.

“Oops, burned up,” Sal said, as the server had announced just that when I fell in the lava.  “Are you the kind of therapist that talks to kids about their problems?”

“Kids and adults both, yes.”

“My mother wants me to see a therapist,” Sal said.

“Why?” asked another one of the kids on the server.

“She says I have problems with friends,” Sal said.  By this point I had returned to the lava pool.  There was no loot that had survived.

“Sal,” I said.  “Everyone needs help with their problems from time to time.  That’s why there are 7 billion people on the planet, to help each other out.”

For some reason that made quite an impact with the other players.  “Wow, you must be an expert!!” one typed.  I’m not sure how he’d come to that conclusion.

“I’m certainly not an expert on lava,” I replied, and fortunately the conversation went back to the business of mining after some sympathetic emoticons.

I have no problem talking with kids about therapy, or being a psychotherapist.  If I did, I certainly wouldn’t have the word in my userid.  And it wasn’t even that I was “off duty.”  I’ve had many conversations in chats over the years and heard a range of problems.  In part I was a little protective of Sal’s right to privacy, although experience has again shown me that kids are often less hung up on therapy than adults, and in many ways are often more trusting of psychotherapy than adults are.  Mostly the reason I wanted us all to get back to playing was that I had caught myself sounding “educational.”

*  *  *  *  *

In play if there is any such thing as an expert it is certainly not the therapist, or adults in general.  Virginia Axline, knew this.  In her book Play Therapy she writes, “Non-directive therapy is based upon the assumption that the individual has within himself…  the ability to solve his own problems satisfactorily.”  (Axline, 1947)  My trainees are often as surprised to find that I am friend to both psychodynamic and solution-focused theories as I am to find that they have been taught the two have irreconcilable differences.

As I see it, my job is often to be a unique experience in the lives of patients.  “It is a unique experience,” Axline writes, “for a child to find adult suggestions, mandates, rebukes, restraints, criticisms, disapprovals, support, intrusions gone.” (Axline, 1947)  And by the time people come to us as adolescents or adults, those suggestions, mandates, rebukes, restraints, criticisms, disapprovals, etc. have become internalized.  By adulthood, many of us feel as if we lack expertise in anything, except perhaps screwing our lives up.

Education has increasingly played a hand in this.  We do not teach so that our students learn to think independently and feel resourcefully.  Instead we teach them to think like someone else.  Critical thinking and exploration become supplanted by the sense that education has to give us something tangible in a materialistic sense:  A good grade; a profitable job; published ideas or maybe if we really drink the Koolaid admiration from other academics.

One thing that is so enjoyable about Minecraft for many is its’ open sandbox environment.  There is an endgame you can play if you want, but there are also myriad variations of play you can do instead.  Sal and millions of other children and adults can range freely through such open and creative spaces without “experts.”  Education certainly can happen there, but often in a lightly curated if not autodidactive way.  People have created versions of Westeros, Middle-Earth, Panem or their own creations.  There are PvP versions where conflict and combat, stealth and griefing hold sway; fantasy realms where people can role-play.  It is a topsy-turvy world where children can have the most wisdom, and we adult experts can trip and fall into lava.

*  *  *  *  *

In a world obsessed with measuring outcomes, psychotherapy can have a rough time of it.  If Sal ever goes to therapy, she will have to be labeled as ill somehow if her mother wants insurance to help pay for it.  Notes will have to be written, treatment plans planned, goals and objectives filed away so bean-counters can determine that Sal should get 14 beans-worth of help.  It’s hard for me to get too angry at the bean-counters though, over the past 25 years I’ve met a few of them and they don’t seem too happy either.

Education fares little better, with things like the Common Core which tells us what should be taught; standardized testing which masquerades as achievement; and trigger warnings which are supposed to warn students of upsetting content as if they somehow were entitled to get through the mind-altering experience of learning without ever being upset.

It takes bravery to stand up to this.  To let the individual chart their own course, make their own mistakes, draw on their own core.  For the therapist and educator it takes bravery to get out of the way, to radically reflect the developing self.  I do believe that each one of us needs help throughout our lives; but that help needs to be asked for lest we run the risk of telling others what to do and implying they aren’t up to the task of living their own lives.

*  *  *  *  *

Many therapists, social workers, and teachers I have met chose to become members of those professions at least in part as an expression of admiration for their own therapists, social workers and teachers.  They had no interest in falling into the lava ever again, so they started focusing on helping other people out.  It’s a thankless job if you are going to go through it secretly hoping to be thanked.  I’m not sure I’ve ever had someone I work with refer to me as an “expert” unless they were being facetious about some blunder I’d just made.  And I’ve made many.  As an apotheosis, being a psychotherapist or academic is rather anticlimactic, not because the work is devoid of meaning or value, but rather because if we truly place such people on a divine pedestal it needs a steady stream of troubled people to hold it steady.

Perhaps an alternative for therapists, social workers, educators and our ilk is to think of ourselves as “lava experts.”  We have some acquaintance with falling into pits, being consumed by intense feelings, losing all our, erm, loot.  These are human experiences.  This is not a secret to anyone, and I doubt most people would put their trust in someone who knows nothing of failure, obsession, overwhelm or grief.

What’s more is we’ve fallen into lava, often the same pit again and again!  We know something of the repetition compulsion.  We have let our yearning for whatever we think we need lead us to risky or self-defeating behaviors.  We can talk to people about their problems, because we are people who have problems ourselves.  We’ve been burned.  Minecraft miners know mining deep is risky:  We know what we’re doing even up to that moment our bones ignite.

Rather than being an expert on a pedestal, accept that you will tumble into fire, again and again, looking outside of yourself for what is precious.  Straight A’s, that book you published, six or seven figures–There’s a little Gollum in all of us.  It’s what makes us forget mindfulness, build empires, win arguments or wars.  No one was ever oppressed by play, only the lack of imagination that comes from the absence of it.

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Using Gaming & Gamification in Clinical Practice

What does “gamification” mean, and what is its relevance to mental health practice?  In this video of a conversation I had at University at Buffalo with Charles Syms, I take a stab at answering those questions.  This is just a start, and hopefully by the end of the video you can begin to see how applying principles of game design could be therapeutic for people dealing with issues ranging from trauma to executive functioning challenges to substance abuse and beyond.

 

 

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The Relationship Between Emerging Technology & Psychodynamic Theory

Often when I present, people are surprised that I teach on both emerging technologies such as social media and video games, and classic psychodynamic theories.  Although it may initially seem counterintuitive, especially to classically trained psychotherapists and social workers, I see a strong connection between the two.  Here is the first in a series of posts featuring work I am doing with the University at Buffalo, in which Charles Syms and I discuss the relationship between the two.

 

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Social Justice & Technology Revisited

mccormick_reaper

I have written before about how technology often makes life easier for a large number of the population while simultaneously disenfranchising others.  The good news is that this does not have to be the case.

The example I used in the past was the Starbucks App which allows customers to use, gain rewards for, and reload their account on their smartphone, while making it more cumbersome and difficult to tip baristas.  This again does not have to be an inevitability, but requires Starbucks to enhance the functionality of its App.

So I was pleased to discover (special thanks to my student Marissa for bringing this to my attention) this week that come Wednesday March 19th, Starbucks will be rolling out an update to their smartphone App which allows just that.  You can read more about it at Forbes here.  You will be able to download the update from places like iTunes, and include your tip easily.

While some may dismiss this as a first-world problem, I cannot emphasize how powerful a shift I consider this to be in terms of workers’ rights in the service sector.  I am convinced it comes in part as a result of advocacy by and for workers, and sets the bar higher and yet attainable for corporations to maximize their value to customers while not disenfranchising their employees.

How can you help advocate for social justice in the technology you use?  First, simply by mindful usage.  Take a few minutes today to open your smartphone and make note of the Apps you use most frequently.  Next, ask yourself, who, if anyone is disadvantaged by my using this App?  Just thinking about the connections can be a powerful mental exercise.  Notice how complicated it can get fairly quickly:  If I use Evernote frequently, I am less likely to write things down on paper, which may be good for the environment but may also disenfranchise industrial workers in paper mills.  Hold on, did I say that you had to stop using Evernote or lobby for paper mills?  No, I’m asking us to sit with the complexity of a problem here for a minute to see the larger systems at play.  Technology has always resulted in job loss for some even as it may provide workplace improvements or quality of life for others.  It’s when we don’t think about these things in a more complex way that we stop innovating social justice itself.

Part of what I’m trying to encourage us to see is that social justice, workers’ rights, unions, and any person or group committed to social justice needs to keep pace with innovation and in fact keep innovating themselves.  Technology always runs the risk of disenfranchising people, especially workers.  If the McCormick reaper in a few hours does the day’s job of three workers, what happens to those three workers?  We are still living in a capitalist society in the US, and it is unlikely that as technology improves and reduces the need for human workers that all of these people will be able to afford to turn their minds and lives to the pursuit of art and culture.  Everything isn’t always getting better for everyone in the current system, and we are seeing overcrowding in occupations ranging from factory to legal work.

If social justice advocates, and social workers are to continue to help the disenfranchised, they are going to need to keep pace with technological developments and continue to think innovatively about 21st century equity in complex and sustained ways.  And by the way, thinking, “the gap is just going to get wider, the social fabric is unraveling,” is not an example of innovative thinking, but defeatism that exempts us from the work of innovation.

This brings me back to my social work colleagues, and my continued urging for them to keep pace with emerging technologies, especially if you are touting the concept of social innovation.  Social innovation without leveraging emerging technology will ultimately lead to future disenfranchisement.  If you have a social innovation department in your social work program that doesn’t leverage technology you are not being socially innovative.  I certainly don’t have all the answers, but I know that the answer to social injustice will inevitably need to integrate emerging technology into it.

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Obama, Selfies, Projections & Death

In this video Mike Langlois, LICSW gives an analysis of what the furor around President Obama’s selfie at Mandela’s funeral could say, not about him, but us.

 

 

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Mental Health: Yes, There’s an App for That..

apps2

Nobody wants to be irrelevant, and many mental health practitioners want to try out new technologies like Apps, but how to choose?  Currently the App Store in iTunes makes available 835,440 different Apps, of which approximately 100,000 are categorized as lifestyle, medical or healthcare & fitness.  And Android users have just about as many to choose from according to AppBrain, which says there are a whopping 858870 as of today.  With so many to look at, how can a clinician keep current?  Hopefully we can help each other.

Instead of writing the occasional “Top 10 Post,” I’m setting up a site for you to visit and review different Apps.  I’ll review some too, and hopefully by crowd sourcing we can get a sense of what are some of the best.  I’ll need Android users to weigh in heavy, as I will be test-driving Apple products alone.

Why have I decided to do this?  Several reasons, the complicated one first:

1. Web 2.0 is interactive.  We forget that, even those of us who are trying to stay innovative.  We keep thinking we need to get on the podium and deliver lectures, information, content.  And to a degree that is true, but we can easily slide back to the old model of doing things.  That’s what you see in a lot of our well-intentioned “Top 10 App” posts and articles.  Recently I found myself trying to explain on several occasions why doing a lecture or post on the best Apps for Mental Health didn’t sit right with me.  Part of it was because Apps are put out there so fast, and then surpassed by other apps, that it becomes a bit like Project Runway:  “One day you’re in, the next day you’re out.”

I was getting trapped behind that podium again, until I realized that we don’t need another post about the top 10 mental health apps, we need an interactive platform.  I need to stop acting as if I’m the only one responsible for delivering content, and you need to break out of the mold of passive recipient of information.  I’m sure that many of my colleagues have some suggestions for apps that are great for their practice, and I’m hoping that you all share.  Go to the new site, check out some of the ones I mentioned, and then add your own reviews.  Email me some apps and I’ll try ’em and add them to the site.  Let’s create something much better than a top 10 post with an expiration date, let’s collaborate on a review site together.  Which brings me to:

2.  I want to change the world.  That is the reason I became a social worker, a therapist, and a public speaker.  I think ideas motivate actions, and actions can change the world. The more access people have to products that can improve their mental health, the better.  By creating a site dedicated solely to reviewing mental health applications, we can raise awareness about using emerging technologies for mental health, and help other people improve their lives.  Technology can help us, which brings me to:

3.  Technology can improve our mental health.  Yes, you heard it here.  Not, “we need to be concerned about the ethical problems with technology X,Y or Z.”  “Not, the internet is making us stupid,” or “video games are making people violent,” but rather an alternate vision:  Namely, that emerging technologies can allow more people more access to better mental health.  Let’s start sharing examples of the way technology does that.  There are Apps and other emerging technologies that can help people with Autism, Bipolar, Eating Disorders, Social Phobias, Anxiety, PTSD and many more mental health issues.  I can’t possibly catalog all those alone, so I’m hoping you’ll weigh in and let me know which Apps or tech have helped you with your own struggles.

Is this the new site, Mental Health App Reviews, a finished product?  Absolutely not.  What it will be depends largely on all of us.  This is how crowd sourcing can work.  This is how Web 2.0 can work.

If you want to contribute, just email me at mike@mikelanglois.com with the following:

  • App name
  • Screenshot if possible
  • Price
  • Link to App

and I’ll take it from there.  Please let me know if you are a mental health provider and or the product owner in the email as well.

You can also contribute by reviewing the Apps below that you use.  Be as detailed as possible, we’re counting on you!  And while you’re at it, follow us on Twitter @MHAppReviews

Innovation is Dangerous & Gaming Causes Asperger’s

GamerTherapist blog is on vacation and will return with new posts after Labor Day.  In the meantime, here is a reader favorite:

At its heart, diagnosis is about exerting control.  Clinicians want to get some sense of control in understanding a problem.  We link diagnosis to prognosis to control our expectations of how likely and how much we will see a change in the patient’s condition.  Insurance companies want to get a handle on how much to spend on who.  Schools want to control access to resources and organize their student body.  And with the current healthcare situation, the government is sure to use diagnosis as a major part of the criteria in determining who gets what kind of care.

Therapists and Educators do not like to think of ourselves as controlling people.  But we often inadvertently attempt to exert control over our patients and entire segments of the population, by defining something as a problem and then locating it squarely in the individual we are “helping.”

This week has been one of those weeks where I have heard from several different colleagues about workshops they are attending where the presenters are linking Asperger’s with Gaming Addiction:  Not in the sense of “Many people on the Autism Spectrum find success and motivation through the use of video games,” but rather in the sense of “excessive gaming is prevalent in the autistic spectrum community.”

This has always frustrated me, for several reasons, and I decided its time to elaborate on them again:

1. Correlation does not imply Causation.  Although this is basic statistics 101 stuff, therapists and educators continue to make this mistake over and over.  Lots of people with Asperger’s play video games, this is true.  This should not surprise us, because lots of people play video games!  97% of all adolescent boys and 94% of adolescent girls, according to the Pew Research Center.  But we love to make connections, and we love the idea that we are “in the know.”  I can’t tell you how many times when I worked in education and clinics I heard talk of people were “suspected” of having Asperger’s because they liked computers and did not make eye contact.  Really.  If a kiddo didn’t look at the teacher, and liked to spend time on the computer, a suggested diagnosis of Autism couldn’t be far behind.  We like to see patterns in life, even oversimplified ones.

2. Causation often DOES imply bias.  Have you ever stopped to wonder what causes “neurotypical” behavior?  Or what causes heterosexuality for that matter.  Probably not.  We usually try to look for the causation of things we are busily pathologizing in people.  We want everyone to fit within the realm of what the unspoken majority has determined as normal.  Our education system is still prone to be designed like a little factory.  We want to have our desks in rows, our seats assigned, and our tests standardized.  So if your sensory input is a little different, or your neurology atypical, you get “helped.”  Your behavior is labeled as inappropriate if it diverges, and you are taught that you do not have and need to learn social skills.

Educators, parents, therapists and partners of folks on the Austism Spectrum, please repeat this mantra 3 times:

It is not good social skills to tell someone they do not have good social skills.

By the same token, technology, and video games, are not bad or abnormal either.  Don’t you see that it is this consensual attitude that there is something “off” about kids with differences or gamers or geeks that silently telegraphs to school bullies that certain kids are targets?  Yet, when an adolescent has no friends and is bullied it is often considered understandable because they have “poor social skills and spend too much time on the computer.”  Of course, many of the same kids are successfully socializing online through these games, and are active members of guilds where the stuff they hear daily in school is not tolerated on guild chat.

Let’s do a little experiment:  How about I forbid you to go to your book discussion group, poker night, or psychoanalytic institute.  Instead, you need to spend all of your time with the people at work who annoy you, gossip about you and make your life miserable.  Sorry, but it is for your own good.  You need to learn to get along with them, because they are a part of your real life.  You can’t hide in rooms with other weirdos who like talking about things that never happened or happened a long time ago; or hide in rooms with other people that like to spend hours holding little colored pieces of cardboard, sort them, and exchange them with each other for money; or hide in rooms where people interpret dreams and talk about “the family romance.”

I’m sure you get my point.  We have forgotten how little personal power human beings have before they turn 18.  So even if playing video games was a sign of Asperger’s, we need to reconsider our idea that there is something “wrong” with neuro-atypical behaviors.  There isn’t.

A lot of the work I have done with adults on the spectrum has been to help them debrief the trauma of the first 20 years of their lives.  I’ve had several conversations where we’ve realized that they are afraid to ask me or anyone questions about how to do things, because they worried that asking the question was inappropriate or showed poor social skills.  Is that really what you want our children to learn in school and in treatment?  That it is not ok to ask questions?  What a recipe for a life of loneliness and fear!

If you aren’t convinced, please check out this list of famous people with ASD.  They include Actors (Daryl Hannah,) bankers, composers, rock stars, a royal prince and the creator of Pokemon.  Not really surprising when you think about innovation.

3.  Innovation is Dangerous.  Innovation, like art, requires you to want things to be different than the way they are.  Those are the kids that don’t like to do math “that way,” or are seen as weird.  These are the “oversensitive” ones.  These are the ones who spend a lot of time in fantasy, imagining a world that is different.  These are the people I want to have over for hot chocolate and talk to, frankly.

But in our world, innovation is dangerous.  There are unspoken social contracts that support normalcy and bureaucracy (have you been following Congress lately?)  And there are hundreds of our colleagues who are “experts” in trying to get us all marching in lockstep, even if that means killing a different drummer.  When people try to innovate, they are mocked, fired from their jobs, beaten up, put down and ignored.  It takes a great deal of courage to innovate.  The status quo is not neutral, it actively tries to grind those who are different down.

People who are fans of technology, nowadays that means internet and computing, have always been suspect, and treated as different or out of touch with reality.  They spend “too much time on the computer,” we think, until they discover the next cool thing, or crack a code that will help fight HIV.  Only after society sees the value of what they did do they get any slack.

Stop counting the hours your kid is playing video games and start asking them what they are playing and what they like about it.  Stop focusing exclusively on the “poor social skills” of the vulnerable kids and start paying attention to bullies, whether they be playground bullies or experts.  Stop worrying about what causes autism and start worrying about how to make the world a better place for people with it.

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Guild Wars: The Conservative Attack on Online Therapy

Commercial-routes

“European commerce during the Dark Ages was limited and stifled by the existence of a multitude of small kingdoms that were independently regulated and who suppressed the movement of goods across their borders through a confusing and inconsistent morass of taxation, tariff, and regulation. This forced merchants to find another solution to move their goods, one that would avoid the strangulation that resulted from this cumbersome regulatory model. These merchants chose to move their goods by sea without being subject to the problems that were created by this feudal and archaic design, a move that changed the world. The little kingdoms took hundreds of years to catch up.”

–Harris, E., & Younggren, J. N. Risk management in the digital world.

Keeping up with policy is not my favorite thing:  But if I am to continue to be a consultant to therapists building their business and an educator on integrating technology into social work practice, it is part of the prep work.  So when a recent client asked me a question about licensure and online therapy in our Commonwealth of Massachusetts I surfed on over to our Division of Professional Licensure to take a look.  Good thing I did, and a lesson for all of you thought leaders and innovators out there, regardless of what state you live in.

There wasn’t much about technology, except for the interesting fact that the past several Board Meeting minutes made mention of a Committee discussion open to the public on “E-practice policy.”  I assumed (correctly it turns out) that this meant that the Social Work Board was formulating a policy, so I reached out to the Division and asked some general questions about what it was going to look like.  The answer was prompt and pretty scary.

The representative stated in her email to me that the “Board ​feels ​as ​if ​the ​use ​of ​electronic ​means ​should ​be ​employed ​as ​a ​last ​resort ​out ​of ​absolute ​necessity ​and ​it ​is ​not ​encouraged. ​The ​social ​worker ​would ​have ​the ​burden ​of ​proof ​that ​electronic ​means ​were ​employed ​as ​a ​last ​resort ​out ​of ​absolute ​necessity.”

I have several concerns about this.

Before elaborating on them, I want to explain that my concerns are informed by my experience as a clinical social worker who has used online therapy successfully for several years, as well as an educator nationwide on the thoughtful use of technology and social work practice.  I have had the opportunity to present on this topic at a number of institutions including Harvard Medical School and have created the first graduate course on this topic for social workers at Boston College.  In short, this issue is probably the most defining interest and area of study in my career as a social work clinician, educator and public speaker.

I also am a believer in regulation, which is why I have been licensed by the Board of Licensure in Oregon, and am in process of similar applications in several states, including CA, and NY, so that I may practice legitimately in those jurisdictions. I am a very concerned stakeholder in telemedicine and here are only a few of my concerns about a policy of “extenuating-circumstances-only-and-be-ready-to-prove-it:”

 

  1. E-Therapy is an evidence-based practice.  It has been found to be extremely efficacious in a number of peer-reviewed studies, over 100 of which can be found at  http://construct.haifa.ac.il/~azy/refthrp.htm .  In fact, telemedicine has been found to have comparable efficacy to in-office treatment of eating disorders (Mitchell et al, 2008,) childhood depression (Nelson et al, 2006,) and psychosocial case management of diabetes (Trief et al, 2007) among others.   To limit an efficacious modality of treatment by saying it needs to be used only in an “extenuating” circumstance or as a last resort which is discouraged would be a breathtaking reach and troublesome precedent on the part of the Board, which has not been done with any other treatment modality to the best of my knowledge.  Telemedicine was also endorsed by the World Health Organization 3 years ago.  And as I wrote this post, the University of Zurich released research showing online therapy is as good as traditional face-to-face therapy, and possibly better in some cases (Birgit, 2013.)
  2. To place and require a burden on the individual social worker to account for why this treatment modality is justified by necessity of extenuating circumstances also raises the issues of parity and access.  Providers familiar with the issue of mental health parity will hopefully see the parallels here.  Clinical social workers for example may become more reluctant to work with patients requiring adaptive technology if they realize that they could be held to a higher level of scrutiny and documentation than their counterparts who do not use online technology.  Even though the Board would possibly deem those circumstances “extenuating” it would require an extra layer of process and bureaucracy that could have the side effect of discouraging providers from taking on such patients.
  3. Insurers such as Tricare and the providers in the military are increasingly allowing for reimbursement for telemedicine; and videoconferencing software is  becoming more encrypted and in line with HIPAA.  While these should not be the reasons that drive telemedicine in social work, we should consider that a growing segment of the population finds it a reputable form of service delivery.
  4. Such policies require input from people with expertise in clinical practice, the law,  technology, and the integration of the three.  When I asked about whether any members of the Board had experience with the use of different newer technologies in clinical practice or how to integrate them, I was informed that “the ​Board ​is ​comprised ​of ​members ​with ​diverse ​backgrounds. ​They ​have ​reviewed ​the ​policies ​and ​procedures ​for ​electronic ​means ​for ​many ​other ​jurisdictions ​as ​well ​as ​the ​NASW ​and ​ASWB ​Standards ​for ​Technology ​and ​Social ​Work ​Practice ​in ​addition ​to ​the ​policies ​set ​forth ​for ​Psychologists, ​LMHC’s ​and ​LMFT’s ​in ​MA.”

The NASW policy which I believe she is referring to was drafted 8 years ago in 2005.  For context, it was drafted 5 years before the iPad in 2010, 2 years before the iPhone in 2007, and 4 years before the HITECH act in 2009.  In fact, the policy I reference says nothing about limiting technology such as online therapy to “last resort;” rather it encourages more social workers and their clients to have access to and education about it. That professional organizations may be lagging behind the meaningful use and understanding of technology is not the Board’s fault.  But to rely on those policies in the face of recent and evidence-based research is concerning.  If the Board does wish to be more conservative than innovative in this case, I’d actually encourage it to consider the policy adopted by the Commonwealth’s Board of Allied Mental Health Professionals at http://www.mass.gov/ocabr/licensee/dpl-boards/mh/regulations/board-policies/policy-on-distance-online-and-other.html which in fact does not make any mention of setting a criteria of extenuating circumstances or potentially intimidate providers with the requirement of justification.

I hope the Board listens to my concerns and input of research and experience in the respectful spirit that it is intended. I am aware that I am commenting on a policy that I have not even seen, and I am sure that the discussions have been deep and thoughtful, but I know we can do better.  As a lifetime resident of Massachusetts, I know we take pride in being forward thinkers in public policy.  Usually we set the standard that other states adopt rather than follow them.  I invited the Board to call upon me at any time to assist in helping further the development of this policy, and reached out to state and national NASW as well.  I hope they take me up on it, but I am not too hopeful.  I had to step down from my last elected NASW position because I refused to remove or change past or future blog posts.

If you practice clinical social work or psychotherapy online, it’s 3:00 AM:  Do you know what your licensing boards and professional organizations are doing?  Are they crafting policies which are evidence-based and value-neutral about technology, or are they drafting policies based on the feelings and opinions of a few who may not even use technology professionally?

This is a big deal, and you need to be involved, especially if you are pro-technology.  The research from Pew Internet Research shows that people age 50-64 use the internet 83% of the time, about 10% less than younger people; and only 56% of people 65 or older do. These older people and digital immigrants are often also the decision-makers who are involved in policy-making and committees.

If you don’t want to practice online, you may bristle at this post.  Am I saying that older people are irrelevant? No.  Am I saying that traditional psychotherapy in an office is obsolete? Absolutely not.  But I am saying that there is a backlash against technology from people who are defensive and scared of becoming irrelevant, and fear does not shape the best policy.  Those of us with experience in social justice activism know that sometimes we need to invite ourselves to the party if we want a place at the table.

And with government the table is often concealed behind bureaucracy and pre-digital “we posted notice of this public hearing in the lobby of the State House” protocols.  My local government is relatively ahead of the curve by posting minutes online, but I look forward to the day when things are disseminated more digitally, and open to the public means more than showing up at 9:30 AM on a work day.  If they allow videoconferencing or teleconferencing I will gladly retract that.

At its heart, divisions of professional licensure are largely about guildcraft:  They regulate quality for the good of the whole guild and the consumers who purchase services from guild members.  They establish policies and sanction members of the guild as part of establishing and maintaining the imprimatur of “professional” for the entire guild.  They develop criteria both to assure quality of services and to regulate the number of providers allowed in the guild with a certain level of privileges at any time:  LSWs, LCSWs, and LICSWs are the modern-day versions of Apprenctice, Journeyman and Master Craftsman.  This is not to say guilds are bad, but it is to say that we need more of the senior members of the guild to advocate for technology if they are using it.

Too often the terms “technology” and “online therapy” get attached to term “ethics” in a way that implies that using technology is dangerous if not inherently unethical.  That’s what I see behind the idea that online therapy should only be used as a “last resort.”  We thought something similar about fire once:  It was mysterious to us, powerful and scary.  So were books, reading and writing at one point:  If you knew how to use them you were a monk or a witch.

Technology has always been daunting to the keepers of the status quo, which is why you need to start talking to your policymakers.  Find out what your licensing boards are up to, advocate, give them a copy of this post.  Just please do something, or you may find your practice shaped in a way that is detrimental to your patients and yourself.

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References

Birgit, W., Horn, A. B., & Andreas, M. (2013). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal Of Affective Disorders, doi:10.1016/j.jad.2013.06.032

Funderburk, B. W., Ware, L. M., Altshuler, E., & Chaffin, M. (2008). Use and feasibility of telemedicine technology in the dissemination of parent-child interaction therapy. Child Maltreatment, 13(4), 377-382.

Harris, E., & Younggren, J. N. (2011). Risk management in the digital world. Professional Psychology: Research And Practice42(6), 412-418. doi:10.1037/a0025139

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., et al. (2008). A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour Research & Therapy, 46(5), 581-592.

Nelson, E., Barnard, M., & Cain, S. (2006). Feasibility of telemedicine intervention for childhood depression Routledge.

Trief, P. M., Teresi, J. A., Izquierdo, R., Morin, P. C., Goland, R., Field, L., et al. (2007). Psychosocial outcomes of telemedicine case management for elderly patients with diabetes. Diabetes Care, 30(5), 1266-1268.