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The Lab: virtual worlds and support for Asperger’s

This story originally appeared over at The Metaverse Journal.

Over the past few months or I’ve followed the efforts of Dale Linegar and Stefan Schutt in establishing what is now known as The Lab. Dedicated to providing support and skills to 10-16 year olds with Asperger’s Syndrome, The Lab is already showing some great results. It’s one of those initiatives that deserves much more kudos and funding than it is currently receiving. You’ll understand why after reading the interview I conducted with the Lab’s co-founders.

David: First, a little about The Lab team. Can you give a snapshot of your backgrounds?

Stefan: For the last seven years I’ve been an educator and researcher at Victoria University, working with technology and young people and teaching multimedia. Before this I worked in the Internet industry during and after the dot com boom as a content editor, producer, web developer and interaction designer. I also set up Australia’s first Computer Clubhouse, a tech skills club for underprivileged kids in Fitzroy based on the model established by the MIT Media Lab in Boston. Before all this, I worked as a writer and played in bands.

Dale: I started working with Stefan at Victoria University (VU) in 2007, teaching in Creative Industries. He had a lot of faith in the virtual worlds work I was doing then, and we have collaborated on at least half a dozen projects together since. We work well together, our skills complement each other. I run a business called Oztron, which does work for VU, Monash School of Pharmacy, and a range of other clients – most involving research and education in virtual worlds.

David: So what specifically has let you to working in this area?

Stefan: We had taught multimedia students with Asperger’s at VU and they seemed to particularly enjoy working with technology, especially the virtual worlds activities Dale was running. This led to a trial with two teenagers in Gippsland funded by Optus Communities. The results were promising and from this we applied to VicHealth for a one-on-one research project to pilot different kinds of technologies with young people with disabilities and other disadvantages. This project found that one-on-one technical tutoring seemed to work particularly well with kids with Asperger’s, and this led to the setting up of The Lab.

Dale: I think after that there were a few factors involved with us deciding to give this a go. We had established through those projects that this approach could work, and that there was a need for it. Once you reach this stage you can either publish and hope that somebody will eventually read what you write and take action, or you can give it a go yourself. The amount of money involved wasn’t huge so we decided to do it ourselves. At this time I was also meeting one young boy with Asperger’s and his mother for regular mentoring at McDonalds, we initally started at the library but were told we were making too much noise. This wasn’t ideal, and it required a lot of travel time to deal with one person.

All of this coincided with my business needing a physical location to work on a few larger contracts. This has provided us with the space, the technology and the human resources required to run The Lab.

David: For those not in the know, how prevalent is Asperger’s amongst the teen population?

Stefan: For Autism Spectrum Disorders (ASD) in general (which includes Asperger’s Syndrome), estimates for Victoria ranged in 2006 from 27 per 10 000 to 54 per 10 000. The prevalence appears to be increasing rapidly and there is debate about whether this is due to increased rates of diagnosis or increasing numbers of people with ASD.

David: Onto The Lab: it’s only just really started in earnest, what’s the journey been like to get to this stage?

Dale: Fascinating and rewarding. It’s a simple idea but when you see the immediate impact it has on both the children and their parents it’s incredibly satisfying. The process actually started with myself and Stefan walking around Footscray knocking on doors asking about vacant office and retail spaces. After a few hours we had found a suitable space, and once it becomes real like that, it takes on a life of its own. It took around 5 months from that day until we opened the doors for kids.

Some simple tasks have turned out to be a nightmare, like getting connected to the internet, and other things which initially seemed complex, like getting somebody who could work with the parents on board, involving our technology mentors, and attracting the right young people, have worked out better than we dared imagine. The physical space The Lab is in is also Oztron’s office, and it has been designed to encourage collaboration. The kids are very comfortable there – it feels more like some kind of gaming den than an office or school.

Stefan’s role at Victoria University and our previous project work means that we have a wide support network, and we have drawn on that throughout the process for advice and support in the many areas we lack knowledge in.

David: So who is funding The Lab at present and is the funding relatively secure?

Stefan: The Lab is currently unfunded, or more accurately, indirectly funded through the virtual world software development projects Dale runs for a range of organisations, as well as small amounts of left over funding from previous VU projects. Funding may be forthcoming later in the year via a Cooperative Research Centre in youth, technology and wellbeing run by the Inspire Foundation that we’re part of – but this is yet to be fully discussed with the CRC. Until then, we’re looking for other funding sources.

David: What is the scope of activities The Lab is involved in?

Dale: We currently run one session a week for 3 hours for 8 kids, and more sessions during holidays for a wider audience. What we try to do is provide as many different technology platforms as possible for the young people, which they can use to explore their own interests. Our aim is not to lead the students, but to support them and encourage collaboration. We provide students with a laptop stand, keyboard, mouse, second monitor, and network connection. We have a local server which is currently running Minecraft and allows filesharing – the kids can also log into this and play together from home. Once the kids come in it’s a case of – ‘What do you want to do?’

One of the hit pieces of software so far has been Minecraft, and this has ended up serving as a social and creative outlet for the kids. For young people who need to learn about social interaction, this has been great, they need to co-operate and respect each others’ territory. Last week we introduced an Arduino, an open-source electronic hardware and software kit comprising of a circuit board that can be programmed to do specific things, starting with simple things like making flashing lights and musical instruments and going up to projects like complex sensor-based triggering and robots with avoidance detection. The Arduino proved to be very popular, and we have now ordered a few more kits. It’s a great way to introduce kids to programming because the payoff is immediate and satisfying.

We also have a separate room where Stefan and Trish (our parent co-ordinator) hold an informal gathering for the parents each week. This gives both the kids and parents a bit of personal space. They can chat about issues they are having over a cup of tea, and discuss possible avenues of support. Trish has just organised for a psychologist to attend every fortnight, and we also have other experts with an interest in the field dropping by to offer assistance.

David: You use OpenSim, Spore and Minecraft to name three virtual environments. Let’s talk OpenSim first: has it primarily been a cost issue that’s led to its use versus say Second Life, or has there been other advantages to OpenSim?

Dale: As a business we use Opensim for nearly all of our work at the moment including Pharmatopia for Monash and a construction world for Victoria University. Second Life doesn’t provide a space where where we have total control, and people of all ages can interact, so as educators we were forced to make the switch a couple of years ago now. Like many people out there I personally have a love/hate relationship with Second Life – I love the possibilities it has created, but I have issues with the way it has been managed and promoted.

David: So what exactly are you doing in OpenSim?

Dale: We haven’t really introduced it to the wider group at The Lab because we are waiting for that opportunity to present itself, it’s up to the kids. We will run our own Opensim world which will be available to the group only – the plan is to create 8 islands and the rest is up to them. Many of the young people with Asperger’s we have worked with over the past couple of years continue to use Second Life. One young lady is using Second Life to bring her characters to life. She has written an amazing story about a group of female superheroes, and drawn pictures, and is now using the virtual world to bring her characters into the third dimension.

Another young man we work with has his dream house in Second Life and is constantly renovating, he lives in rural Victoria so for him it’s a great escape. We have also used Comic Life quite a bit in the past and will probably introduce this to interested Lab participants at some stage.

David: A common criticism of OpenSim (and Second Life) is the initial learning curve: has that been a greater or lesser issue with the teens you’ve been working with?

Stefan: Yes and no. What surprised us in our last project is how much Second Life and OpenSim rely on text-based navigation. We’d always thought of them as visual interfaces until then, but as we found out when working with kids with very low literacy levels, so much of the navigation is achieved by typing in text, which can cause issues for some kids. For others, they’ve taken to it like ducks to water, especially the younger ones. We also wonder whether the ‘learning curve’ referred to is related only to the ‘end user’ or also the people running the activity (ie teachers and managers) – this is where a lot of the problems seem to arise in terms of access, web speeds, and associated lag, plus generational issues like people not used to navigating in 3d or navigating via arrow keys like, erm, me. I always get Dale to do the practical demos because I’m so unskilled at it!

David: Now onto Spore: how are you using it?

Dale: We only use the free creature creator, firstly because it’s free, and secondly because it’s all about being creative. It’s a great icebreaker, many of the young kids we work with have already played it, and it acts as a catalyst for communication. It also gets kids into a more creative frame of mind, to feel the pleasure of making something as opposed to getting stuck competing in other games.

David: And Minecraft?

Dale: It can appear to an outsider as one of those ‘click-click-click’ games but when the kids are playing on a server together it allow for some wonderful creativity and encourages communication and collaboration. One of our mentors has built his own computer in it and knows it backwards, and the kids respect this.

David: Has Minecraft been a bit of a revelation for the work you are doing? It sort of came out of nowhere and has caught on quickly.

Dale: It has been surprising how many of the kids enjoy it, I think every one of them has played it at some stage now, and there are regularly 5 or 6 of the kids on the server during our sessions. There is a lot to learn, so I see it as the group exploring a new territory together – in this case a virtual one. They feed off each other and go on journeys, learning things they might not learn alone.

David: Talking more broadly again now, what are the individual benefits and outcomes you’ve seen so far amongst the participants?

Stefan: One big factor so far seems to be the environment of The Lab – i.e. a space where young people with Asperger’s are not picked on (unlike school, where bullying is constant), where they’re accepted and where being a ‘geek’ is even cool, and where they are surrounded by other people like them – both other kids and the programmers who are a kind of role model. Also, where their parents aren’t hovering the whole time! They’re relaxed because they’re not pushed to do anything, or to interact if they don’t want to. They can sit happily at the screen without being bugged – but the expert advice is on hand whenever they request it.

Having said that though, the level of kid-to-kid interaction to date has been quite amazing – here we’re talking about kids who don’t have any friends at all in the outside world, but who are happily chatting away and playing with others, both in-world and in the physical space.

Another factor is the technology itself, and the presence of experts to whom they can look up and respect (they usually run rings around other adults when it comes to IT). Tied to this is the sense of possible future careers, and a way into the future. This is very powerful – already we’ve heard reports of one parent halving her child’s anxiety medication dose due to his reduced anxiety levels about his future.

David: Let’s talk research: is there an underlying research methodology being used for The Lab?

Stefan: We would classify our approach as ‘participatory action research’ – our focus is on hands-on outcomes driven by all stakeholders in collaboration, and implemented (and continuously improved) by all involved. It’s based on making a real difference to real people’s lives rather than sitting back as the researchers in the white coats. It’s proudly interventionist and practical, and has a strong element of social activism.

David: Are there specific research projects underway and if so can you give a brief overview of any?

Dale: The Lab is it! We may choose to work with others in the future to measure outcomes empirically – especially researchers who are experts in ASD (which we’re not)

David: What are the measures of success for you with The Lab?

Stefan: In the short term, happier kids, happier families, and a sense of progress amongst participants. We rely heavily on feedback from the kids and the parents. It will always be tough to measure our impact in a quantitative way as each of these young kids is so unique and we are only dealing with small numbers. It’s not like we can create a control group. But we are looking to work with experts in the Autism field who may be able to measure the effects on individuals and their families over time – this is where the Cooperative Research Centre, and its 70 or so partner organisations, will hopefully come in.

David: Are there any qualitative or quantitative outcomes you’re able to see already?

Stefan: Yes. We’ve already had remarkable email and verbal feedback from participants’ parents about their children’s improvement, only three weeks into the beginning of the program. We also have 20 plus kids on our waiting list. Other parents have been ringing us daily after finding out about The Lab. It seems to have really hit a nerve. As stated previously, we’d like to get other measures too, working with field experts.

David: Given the central use of virtual environments in the program, are there any plans to expand the program geographically?

Stefan: Currently The Lab has three interlocking elements that work together: participant socialisation, technical tuition and parental networking/support. Any of those three elements would be useful in themselves (for instance, we’re arranging for a software engineer to undertake private volunteer programming tuition with one of the kids on our waiting list), but the combination of the three is especially powerful. So we could run virtual programs, and they could be useful, but some of those three elements might be missed.

Dale: My feeling is that having personal contact is still important in modern society, in this case for both the kids and their parents. We hope to build online resources which can help people at home, but nothing beats a one-to-one conversation with somebody who knows what they are talking about. I hope that we can inspire other real-world institutions to become involved.

David: Getting out the crystal ball: what are you hoping The Lab has achieved a year from now?

Stefan: What we are striving for is an effective model that can be replicated in other places and can positively influence the way society thinks about these kids, particularly in the education system which seems to be manifestly unsuited to a group of young people who are very talented.

Dale: Currently so many of the young people and their parents simply have nowhere to turn – they are stuck between normal schools and special schools, neither of which meet their needs. These people have a lot to offer to society – we deal with kids who can program their own games, but aren’t able to attend school and are at risk of being disadvantaged their entire lives. I hope that we can help support people and organisations who are interested in adopting this type of model, and I hope we can expand and deal with more kids more regularly. We live in an age where we have the opportunity to use technology to create
positive social change, and we are enjoying every moment of it.

Interview: Andrew Campbell – Director of Prometheus Research Team, University of Sydney

Update (July 2014): I had the opportunity to check in with Andrew and he’s confirmed the below interview still represents the state of play in regard to the opportunities gaming can bring. Additionally, he recommended a resource he’d been involved in which outlines the use of technology in promoting young people’s wellbeing. You can access that here.

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Over the past couple of years I’ve had the opportunity to chat with Andrew Campbell on a couple of occasions. As Director of the Prometheus Research Team, Andrew is heavily involved in the area of mental health and technology. I’ve always been struck by Andrew’s objective view of gaming and virtual worlds, which he rightly sees as simultaneously providing significant opportunities and challenges.

I caught up with Andrew to discuss his work and perspectives on mental health, gaming and immersive virtual worlds.

DH: Can you describe the main focus of your clinical work?

AC: The main focus of my clinical work is divided into two categories. Firstly, research. My primary job is an academic researcher and teacher in the field of Psychology. I conduct research particularly in the area of Cyberpsychology, which is the study of how technology is impacting human behaviour, both in good and bad ways. Secondly, I am a general practice psychologist who specialises in child and adolescent mental health and behavioural problems. My clinical work to date has been focused on treating children with ADD/ADHD, anxiety and depression, conduct problems, as well as parental counselling and family therapy.

DH: What led your career to the stage it is at today – what got you into the issue of mental health and technology?

AC: In 1997 I was finishing my undergraduate degree in Psychology and Education at The University of Sydney and decided to spend some time in the United States working as a teaching assistant at a few universities. I became captivated with work being done by a handful of academic psychologists in the US at the time who were focusing on how the internet was going to be a revolution to impact human behaviour and society at large.

Campbell_Andrew I read everything I could get my hands on at the time to do with online relationships, virtual societies and even gaming communities that were developing international reputations and new cultures in cyberspace. I asked myself at the time ‘could this be the start of a new movement in human enrichment?’ and set forth to find out the good and the bad (and the down-right terrible) aspects of spending a lot of time engrossed in an online world, be it chat, gaming, shopping, finance, politics etc. Thus, my interests turned toward career aspirations to develop psychological research and an applied track record in the use of information communication technology and the use of other technologies in helping the ‘human condition’.

DH: Arguably the number one and two areas of broader public interest with mental health and technology is gaming and violence and addiction. What percentage of your work is spent dealing with actual or perceived issues in those areas?

AC: To date, my clinical work as a generalist psychologist in child and adolescent mental health has only touched lightly on these issues. I have mainly dealt with traditional mental health concerns of parents over their children, but of those clients I have seen about gaming violence and addiction, I’ve noted that the parents themselves do not know anything about the games their children are playing. They tend to have a view that all games are violent or addictive. Given this, I normally direct parents to learn more about what their kids enjoy about their game in order to learn more about behaviours they may be modeling from the game. For example, two of my client’s parents had no idea that strategic games such as ‘Age of Empires’ actually have huge cognitive and historic learning benefits. The game is akin to modern day chess, with historical lessons of ages past. Other games that promote team play
increase problem solving skills in a collaborative environment, therefore promoting team work and clear communication strategies.

Adversely, some team playing games are based on a violent theme, such as the popular game ‘Counter Strike‘. Overall, through my work I’ve found that parents do have concerns about violence and addiction to games, but really do not have an understanding of games themselves. This is troubling in an age where gaming is increasing in popularity across generations and content is still not regulated well by Government or other ‘watchdog’ agencies. As such, parents need to be cognisant of the types of games out there – their pluses and minus points – and be involved in selecting and learning about the titles with their children in order to curtail negative behaviours related to certain genres.

DH: The issue of technology and its influence on behaviour has been around for decades, with the TV / Film and violence link being hotly debated for most of that time. Before we get onto gaming / virtual worlds, is there yet any empirical agreement on TV/Film and violent behaviour?

AC: As surprising as this may sound, no, there is not any empirical agreement on TV/Film and violent behaviour in contemporary society. Incidents such as the Columbine School Massacre and more recently, the Virginia Tech shooting have led psychologists to argue for renewed policies censuring violent films and TV shows from minors and suggestible personality types. Although games are becoming a popular target for connecting atrocious violent crimes to the perpetrator, TV and Film are still front runners in the causation of violent behaviour in, not just the younger population, but the population in general.

DH: The popular media perception of gaming is that there is at least an anecdotal link between the regular playing of violent games and violent real-life behaviour. From your work, have you seen any evidence of this?

AC: Unequivocally, no! To say that violent games or even violent TV/Film is causation for a violent crime is ludicrous. I won’t go so far to say that violent games, TV or Film have zero impact on violent crimes, but to look at it as a sole causation does not address the pathology of the individual to begin with, let alone motive to carry out the behaviour that may lead to a crime. Ergo, playing a violent game is no more likely to trigger someone’s violent behaviour than eating your favourite food is going to motivate you to become a chef! In my private practice, any child who has presented with conduct disorder or oppositional defiant disorder, or even anger management problems, may or may not have been a gamer – however – all have had pathology and environmental problems that
have led to their disorder that are more consistent and pervasive than just playing a violent video game a few hours a day.

DH: Is there actually an argument that gaming can have an ameliorating effect on real-world behaviour and if so, is there research supporting this?

AC: Yes, a number of studies have shown wonderful results helping people to ameliorate either behaviour or, in some cases, the management of pain. My own research has looked at how biofeedback video games that encourage the player to control a task on a screen using their breathing technique, has led to improved attention and relaxation strategies in ADD/ADHD children. Other research has shown that virtual reality games that are immersive can actually help in the treatment of PTSD. One of the best breakthroughs in serious games has been the treatment of burn victims from the current Iraq and Afghanistan wars. These patients have to undertake pain dressing changes and skin grafts. During these procedures, the patient plays a game called ‘Snow world’ which immerses them in an environment that triggers their subconscious into believing they are in a cool and calm environment that distracts them from the pain of the treatment they are receiving. The research in all these examples is very new, but compelling. It is beginning to influence the game developers in entertainment to consider the market for ‘serious games’. This has already commenced with popular programs such as the Nintendo Wii releasing Wii fit and associated sports programs to tackle obesity.

DH: In regards to addiction and online gaming or virtual world environments, what’s your overall take?

AC: My overall take on addiction is that it is possible in either the virtual world or gaming environments online. What needs to be clarified is what aspects of these activities and functions are ‘addictive’. To say we are addicted to the Internet is like saying we are addicted to shopping – what items are we addicted to? The internet houses many areas of interest. It is obvious to posit that sex addiction offline could also be met online, as could be gambling. But gaming offline vs gaming online has different stimulus effects I would theorise.

Also, virtual worlds – what do we gain in socialising in these worlds that we don’t in our offline world? Is there such a thing as addiction to socialising?! Most likely not, because socialising is part of being human. Therefore, what is the attraction to these worlds that stimulates us highly enough to spend hours online engaging with strangers vs. meeting strangers in the offline world? The answer probably lies somewhere between the functions of pursuing anonymity, creativity, cerebral connections and/or reducing the chance of being socially awkward – all reasons one person may prefer the online world.

DH: If addiction is only quantifiable in a small component of the population, is that component larger or smaller than other behaviours such as substance use, gambling etc?

AC: I think if we look at gaming addiction in comparison to substance use, for example, we can quickly conclude that substance abuse is both physically and psychologically damaging and perhaps more wide spread globally across ages, genders and cultures. But the damage of gaming addiction is growing in certain cultures, such as in Asia where gaming is an accepted pasttime for all ages and genders and thus could be on the rise without society realising it since it is not an illegal behaviour or even an invasive or obviously destructive past time compared to drug taking.

prometheus However, it is psychologically damaging both in psychosocial relationships, employment responsibility and accountability and can even affect our general health to a large degree. You might therefore say that although substance abuse and gambling are faster and
harder-hitting addictions, gaming addiction is fast becoming a contemporary societal problem that is slow to build in destructiveness,
but easier to ignore.

DH: For those who do require actual treatment for addiction, what’s your take on the use of online treatment when the issue is related to online behaviour i.e. addressing the traditional view that you can’t use the mechanism for facilitating addiction to treat the addiction itself.

AC: One of the earliest therapies provided online by Psychologist, Dr Kimberly Young, was treatment for online addiction. She began this service, online, in the early 1990’s. Although it has been a growth industry for Dr Young and others who believe in her treatment modality, I personally find it to be flawed therapy and lacking in best-practice evidence. Addiction, be it to specific functions of the internet, gaming, substance abuse, gambling etc, is an extremely difficult pathology to treat, let alone treat well. Therefore, all scientific practice indicates that addiction therapy should be done in a face-to-face or group counselling environment. It requires ongoing resource support utilising mentors, friends and family. It is something that may (but only in very specifically suitable cases) use the internet as a support tool, but in all other regards addiction, especially to internet functions and gaming, should be done away from the primary stimulus.

DH: With growing immersiveness in gaming and in virtual worlds more broadly, what do you see as the mental health challenges and opportunities?

AC: Research right now is looking out how we can harness immersive environments, be they virtual worlds or games, for tackling problems in health, behaviour and education. The challenges we face at the moment are actually not to do with the quality of the environments being delivered to consumers over the internet or through off-the-shelf games, but more through the cost of developing serious games or health purpose virtual worlds by the commercial sector. In addition, we are facing a health professional vs tech industry challenge in trying to have these two expert bodies effectively harness the ideas that are scientifically based delivery of health interventions. In short – the health professionals need to learn more about the tech industry and vice versa. Once this bridge is finally built, I believe we will be entering a new error of technology consumerism – games for wellbeing and ICT for personal health management.

Interview – DeeAnna Nagel and Kate Anthony, Psychotherapists

DeeAnna Nagel and Kate Anthony are psychotherapists and founders of the Online Therapy Institute. The pair have only recently expanded their work to Second Life, but they have extensive experience in working with people therapeutically online. The pair now have a presence on Jokaydia in Second Life. I caught up with them to talk online counselling / therapy.

Lowell: Can you give a brief outline of your professional experience /qualifications pre-Second Life / online therapy?

deanna_inworld

DeeAnna: I have a Master of Education in Rehabilitation Counseling and a Bachelor of Science in Mental Health and Human Services. I have worked in the mental health field for nearly 20 years. About 10 years ago I discovered the power of the Internet and began providing online chat and email through a couple of e-clinics. Over the years I have always maintained a part-time practice online and have integrated technology in work settings working with interns, employees and clinical supervisees. I have been training therapists since 2001 about the ethical issues pertaining to technology and mental health. Now 100% of my work life is devoted to either providing online therapy or teaching others about online therapy.

Kate Anthony: I have a Master of Science in Therapeutic Counselling and a Bachelor of Science in Psychology, and am halfway through a PhD on the topic of Technology and Mental Health. At around the same time as I discovered how powerful relationships over the Internet can be and based my MSc thesis on that. From that, I co-authored the British Association for Counselling and Psychotherapy (BACP) Guidelines for Online work (including Supervision) through its 3 editions. I have trained mental health professionals to work online since 2002, have published widely including textbooks, and was recently made a Fellow of BACP for my work and DA and I are both past-Presidents of the International Society for Mental Health Online (ISMHO).

Lowell Cremorne: What was the event that led to you realising the potential of virtual worlds for counselling interventions

DeeAnna Nagel: There was no single event for me; just a realisation that virtual world settings offer another level of sensory experience that could enhance the therapeutic process.

kate_inworld

Kate Anthony: I realised this in 2001 after speaking at a conference about Telephone Helplines. The Keynote speaker was head of BTExact Technologies, and he referred to the future of virtual worlds, and avatars specifically, being part of the future of health care. Most of the audience was laughing at the concept -– I wasn’t. I went on to work with him and his team to explore the concept and write a white paper on the topic (Anthony, K. and Lawson, M (2002). The Use of Innovative Avatar and Virtual Environment Technology for Counselling and Psychotherapy. Available online at www.kateanthony.co.uk/research).

Lowell Cremorne: Your Online Therapy Institute offers consultancy including advice on marketing counselling services online, but it seems you’ve carefully differentiated your SL consultancy to avatar familarisation etc. Would you agree that virtual worlds as an actual intervention mechanism are not evolved enough yet?

DeeAnna Nagel: The potential for therapeutic intervention in virtual world settings is already available – but not necessarily cost-effective for the private practitioner. Second Life is not encrypted and while we could offer therapy using secure methods such as a Sky Box, we have chosen not to. Proprietary software is being developed by companies and institutions for use in SL and other virtual worlds, and at some point private practitioners will be able to provide secure and encrypted services. Until that happens, we can, as you say, utilise our SL office as a way to meet people who want to provide an avatar representation and for other educational and consultancy opportunities.

Lowell Cremorne: What do you think needs to occur for people to be able to trust in-world therapy?

DeeAnna Nagel: Security including encryption is paramount. In addition, virtual world platforms need to be less cumbersome and be able to run on different platforms without the constant risk of technological breakdowns.

Lowell Cremorne: A common component of media coverage of virtual worlds is addiction – for the small percentage of people who may have a definable addiction, can the cause also play a role in the treatment? What I’m getting at here is whether in-world therapy for those addicted to virtual world interaction is a sensible treatment option or a damaging option.

DeeAnna Nagel: This should be taken on a case-by-case basis- I do offer online text-based therapy via chat and email to people who identify with Internet addiction. I think working with addicts inworld allows the client to experience a healthy relationship online and offers a way to model use of technology in appropriate ways. Technology is such a part of our social and vocational fabric now that people need to be able to integrate back to using technology but in healthy ways with appropriate boundaries. The work becomes about establishing and maintaining healthy relationships just as we have done with face-to-face clients for years.

kate_deanna_inworld

Lowell Cremorne: Rapport-building is key for successful therapy – how best is that done online?

DeeAnna Nagel: Consideration should be given to the disinhibition effect. Online, people are less inhibited and likely to disclose information due to the person’s sense of anonymity. When working therapeutically, on the surface, this can be a plus in establishing rather quick rapport, but therapists also have a responsibility to prepare clients about disclosing personal information too quickly and then helping the client modulate the emotional intensity throughout the process.

Kate Anthony: The concept of “presence” is also important here – where is the client and where are you during the process? Most of my trainees agree post-training that the therapeutic work takes place somewhere between the two pieces of hardware (including mobile hardware) in Cyberspace. The mutual journey – and the rapport that goes with it – seems to take place in a nebulous arena, but actually the understanding by both client and counsellor as to how it exists for them facilitates the rapport.

Lowell Cremorne: How much real-world identification do you believe needs to occur prior to therapy commencing?

Kate Anthony: I think it essential for the client to be able to verify identity of the therapist, but this could be done via a third party – such as a professional organisation. Opinion varies widely from a client-identification point of view. Purists prefer to work with whatever the client is offering, subject to some legal identity checks in some places such as the client possibly being under age. The argument there is that the psyche that the client presents, via avatar or text, is a valid psyche to work with. Other practitioners prefer to make several checks as to how the client exists offline (we feel the phrase “real-world” is outdated, incidentally, so prefer to refer to online and offline). Personally, I feel that with a robust intake form and assessment procedure, further identification may simply get in the way of the therapeutic work which often depends on uniquely online societal norms (such as disinhibition and the perceived anonymity).

kate_deanna

Kate Anthony (L) and DeeAnna Nagel (R)

Lowell Cremorne: Is confirming real world gender / age / cultural identity important for good therapeutic outcomes online?

DeeAnna Nagel: Yes- as with face-to-face, the person’s identification is important to determine if the work between therapist and client is a good fit. Cultural differences should be taken on a case-by-case basis.

Kate Anthony: Yes, particularly with regard to age and informed consent.

Lowell Cremorne: What issues / mental health states would you feel uncomfortable dealing with online?

DeeAnna Nagel: For the most part, I am comfortable working with people online that have issues I am comfortable working with face-to-face. As long as I feel competent about the clinical issues and have the proper training, most mental health interventions can occur online. For me, it is difficult to work with someone who is obviously intoxicated or obviously decompensating and showing signs of delusional and irrational behavior- but this is whether the client is face-to-face or online. Certainly, when working via distance, the client’s geographical resources should be determined should crisis intervention become necessary.

Kate Anthony: And that exact point is how I train upcoming online mental health professionals– that with the Internet it is simple to explore a clients alternative crisis interventions based on their geographical location. Other concerns are working with people who are in a relationship that involves domestic violence. Safety issues for the victim come into play if he or she is using a computer that the perpetrator has access to and may be monitoring with a keystroke program.

Lowell Cremorne: Whether it be in a virtual world or via more traditional online methods, do you find you’re less likely to run into personal boundary issues, or is it just as much a challenge?

DeeAnna Nagel: For me, the boundaries are not blurred. I have always maintained boundaries in person and online but with the advent of social networking, I am consulting with more and more professionals who are struggling with this issue. What to do if a client friends their therapist on Facebook for instance and many times the dilemmas are ethical in nature- with regard to either confidentiality or dual relationships.

Lowell Cremorne: Are you aware of any formalised professional associations for online therapists to communicate and if not, how do you see the momentum developing so that this occurs?

Kate Anthony: There is the International Society for Mental Health Online (ISMHO) as mentioned, and more recently ACTO-UK (Association for Counsellors and Therapists Online – UK) – an organisation for UK based online therapists. The latter is holding it’s first conference (online and offline simultaneously) in April. Our fear is that many small organisations will crop up here and there with narrow ideas – what the Online Therapy Institute strives for is a global agreement as to how each of these associations can work together to disseminate knowledge and stimulate growth of the field to the greater good of online work, whether in virtual worlds or via other modalities.

DeeAnna Nagel: To that end we have developed the Ethical Framework for the use of Technology in Mental Health that offers Best Practice standards regardless of the practitioner’s geographic location.

Lowell Cremorne: What are your plans over the coming year for your Second Life work? Have you considered other worlds?

DeeAnna Nagel: We explore other worlds as they appear, and not always necessarily in an obvious way. For example, the Online Therapy Institute has a strong interest in the prevention and treatment of Cyberbullying, and a virtual world such as Club Penguin, for example, could be instrumental in that aim. Plans for the coming year is to explore those platforms that meet the Institute’s requirements for safe and secure client-therapist interaction, and continue to develop training for conducting therapy in virtual worlds.