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Taking Leaps: Fortnite, HIPAA & Psychotherapy

May 31, 2018 by Leave a Comment

“You keep dying,” Sam* said. The annoyance in the 9 year old’s voice was palpable. I looked at my avatar lying face down on the screen. Another of the 100 players in the game, appearing as a brunette woman in sweats sporting a ponytail, was doing a victory dance with her rifle over me. Sam was nowhere to be seen on the screen, but I knew he was hiding somewhere in the game, and seething.

“You’re disappointed in me,” I said calmly. A moment of quiet.

“Yeah.”

“You were hoping I’d be better at this, as good as you or maybe better, and it’s frustrating.”

“Yeah… Can we try again?”

And so we tried again and again, and while we did I talked with Sam about the other adults who were disappointments to him, who kept leaving or letting him down. And I guessed that we were also talking about his frustration and disappointment in himself. And at the end of our appointment I promised I would practice Fortnite, the game we had been playing. We had turned on our webcams again so we could see each other to finish the session, so I could see that he brightened at this idea.

“Nice to see you again,” I said. He smiled faintly.

“You too.” His screen went dark.

As I reflect on the work I do with patients, meeting them where they are at, I am struck by the same issues, opportunities, and conversations that can happen in an online play therapy session. I only wish more of my colleagues would try it. What gets in the way? For some it is a dismissal of emerging technologies which masquerades a fear of trying something new. For others it is a worry about running afoul of HIPAA and being sued. If you are one of those people who wonders about how to integrate video games online into your therapy practice, read on.

 *  *  *  *  *

Quick, without Googling it; what does the “P” in HIPAA stand for?

If you are a psychotherapist or other health provider, you probably guessed “privacy.” At least that’s often the consensus when I ask this question at my talks. It would be understandable if this was your guess. You’d be wrong.

The correct answer is “portability,” the basic premise that individuals have the right to healthcare treatment that moves with them as they go through the vicissitudes of life and work. That is also where technology comes in– electronic health records, telemedicine, etc., are ways that technology increases portability by collapsing time and space so that the patient and the healthcare professional can get to work.

In therapy, that work traditional has happened in an office setting. And in the case of children and youth especially, that meant play therapy which was bounded by the space and time of a physical office. From Uno to Sandtrays to the infamous “Talking Feeling Doing Game,” we have often assumed that play therapy needs to be the games of our own childhoods. But 21st century play can, and I maintain should, include 21st century play. That’s where video games come in.

In the days of the Atari 2600, there was no worry about patient privacy, because the system was hooked up directly to a television that didn’t even need to be connected to cable. But nowadays with SmartTVs, PCs and PS4s, video games are often played online with many other people and seamlessly connected to voice chat. This can be a concern for the psychotherapist who is unfamiliar with newer technology, especially with games like Fortnite, which boast Battle Royales having as many as 100 players at a time in the same game instance.

Videoconferencing programs and online therapy using video/audio chat have been around long enough to have specifications that adapt to HIPAA’s privacy requirements, largely because there is market force behind developing products that can be sold to the healthcare industry. Video games and their platforms, on the other hand, do not have a similar demand to give them an incentive to supply. Games like World of Warcraft, Platforms like STEAM, and streaming services like Twitch were designed for gamers, not therapists, and it is unlikely they will go through the technical and legal procedures to become HIPAA compliant anytime soon.

Some therapists have begun developing their own video games, which, like most therapy games are dismally boring. They are thinly veiled therapy interventions that are disguised as play, but lack any of the true qualities of play. True, they are more likely private; but they are also boring, and easily recognizable as “not playful” by patients. Mainstream games have broader appeal, critical user mass, and better graphics and gameplay in many cases, and are more immediately relevant to the patient’s life. But they are definitely not HIPAA-compliant. So what to do?

 *  *  *  *  *

My solution, which I’m sharing as an example that has not been reviewed by policy experts, lawyers or the like, has two parts:

  1. Due Diligence– Research the existing privacy settings and technologies to maximize benefit and minimize risk to patient privacy. So for example, I structure the “talk” part of therapy to happen over HIPAA-compliant software like Zoom or GoToMeeting. We start on that platform with video camera on, until we begin playing. Then we, turn off the camera to save on bandwidth and talk over this software, not the game. Previously, I will have sent the patient or their parent a snapshot of the settings of the game we are using with the voicechat disabled if possible. We also want to lower or turn off the game sound so we can hear each other. So in the case of Fortnite, the settings would look like this:

 

2. Limited HIPAA Waiver- This is the part most therapists overlook as even being a possibility. You can ask patients to sign a release waiving in a limited capacity their HIPAA rights in order to use noncompliant technology. It is entirely voluntary and I’ve yet to have a patient decline. I use a informed consent form that I developed that looks like this:

 

These are examples of how to engage with online technologies in a clinical way that is thoughtful yet forward-moving.

 *  *  *  *  *

Whether you love Freud or hate him, most experts agree that he was one of the fathers of modern psychiatry. He was also an early adopter. He based his hydraulic model of the drives on steam technology of his era. His concept of the “mental apparatus” was likewise integrated from the advances in mechanics and his formulation of ego defenses such as projection occurred simultaneously with the Lumiere brothers’ creation and screenings of motion pictures. Regulatory concerns aside, therapists can be early adopters. Doing so would probably help our patients no end, and definitely cut down on my waitlist.

* “Sam” is based on several patients whose identifying information has been disguised to protect patient privacy.

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Selfie Esteem

December 2, 2013 by 6 Comments
Nancy J. Smyth, PhD, Dean & Professor, University at Buffalo

Nancy J. Smyth, PhD, Dean & Professor, University at Buffalo

 

“Photographs do not explain, they acknowledge.” –Susan Sontag

Last month, the Oxford Dictionary made the word “selfie” not only an official word, but their word of the year for 2013.  Defining selfie as “a photograph that one has taken of oneself, typically one taken with a smartphone or webcam and uploaded to a social media website” the OD made explicit what has implicitly grown to be the norm of our world; a world of smartphones, self pics and social media.

Many psychotherapists and social workers have and will continue to decry this as another sign the the “narcissism” of our age.  Selfies have become synonymous with the millenials, the dumbing down of the populace by the internet, and sometimes even stretching to how Google is making us stupid.  My chosen profession has historically played fast and loose with calling people and cultures narcissistic.  Karen Horney coined the term “the neurotic personality of our time” in the 1930s, initially in part as a critique to the Freudian critique of Victorian modesty.  Kohut’s groundbreaking work on “tragic man,” and the healthy strands of narcissism in human life was co-opted within years by Lasch (1979) to describe the then-current “culture of narcissism.”  In short, even though narcissism has been a part of human being at least since Narcissus gazed into the water in Greco-Roman times, we continue to see it as perennially on the uprise.

 

Joanna Pappas, Epic MSW Student

Joanna Pappas, Epic MSW Student

 

This dovetails with each generation’s lament that the subsequent one has become more self-absorbed.  And yet, as Sontag points out, by making photography everyday, “everybody is a celebrity.”  Yep, that’s what we hate about the millennials, right?  They think everything is an accomplishment, their every act destined for greatness.  But as Sontag goes on to say, making everybody a celebrity is also making another interesting affirmation: “no person is more interesting than any other person.”

 

Jonathan Singer, Assistant Professor, Temple University

Jonathan Singer, Assistant Professor, Temple University

 

Why do many of us (therapists in particular) have a problem then with selfies?  Why do we see them as a “symptom” of the narcissism of the age?  Our job is to find the interesting in anyone, after all. We understand boredom as a countertransference response in many cases, our attempt to defend against some projection of the patient’s.  So why the hating on selfies?

I think Lewis Aron hits on the answer, or at least part of it, in his paper “The Patient’s Experience of the Analyst’s Subjectivity.”  In it he states the following:

 

I believe that people who are drawn to analysis as a profession have particularly strong conflicts regarding their desire to be known by another; that is, they have conflicts concerning intimacy.  In more traditional terms, these are narcissistic conflicts over voyeurism and exhibitionism.  Why else would anyone choose a profession in which one spends one’s life listening and looking into the lives of others while one remains relatively silent and hidden?

(Aron, A Meeting of Minds, 1996, p. 88)

 

In other words, I believe that many of my colleagues have such disdain for selfies because they secretly yearn to take and post them.  If you shuddered with revulsion just now, check yourself.  I certainly resemble that remark at times:  I struggled long with whether to post my own selfie here.  What might my analytically-minded colleagues think?  My patients, students, supervisees?  I concluded that the answers will vary, but in general the truth that I’m a human being is already out there.

 

Mike Langlois, PvZ Afficianado

Mike Langlois, PvZ Afficianado

 

Therapists like to give themselves airs, including an air of privacy in many instances.  We get hung up on issues of self-disclosure, when what the patient is often really looking for is a revelation that we have a subjectivity rather than disclosure of personal facts.  And as Aron points out, our patients often pick up on our feelings of resistance or discomfort, and tow the line.  One big problem with this though is that we don’t know what they aren’t telling us about because they didn’t tell us.  In the 60s and 70s there were very few LGBT issues voiced in therapy, and the naive conclusion was that this was because LGBT people and experiences were a minority, in society in general and one’s practice in specific.  Of course, nobody was asking patient’s if they were LGBT, and by not asking communicating their discomfort.

What has this got to do with selfies?  Well for one thing, I think that therapists are often similarly dismissive of technology, and convey this by not asking about it in general.  Over and over I hear the same thing when I present on video games–“none of my patients talk about them.”  When I suggest that they begin asking about them, many therapists have come back to me describing something akin to a dam bursting in the conversation of therapy.  But since we can’t prove a null hypothesis, let me offer another approach to selfies.

All photographs, selfie or otherwise, do not explain anything.  For example:

 

looting

 

People who take a selfie are not explaining themselves, they are acknowledging that they are worth being visible.  Unless you have never experienced any form of oppression this should be self-evident, but in case you grew up absolutely mirrored by a world who thought you were the right size, shape, color, gender, orientation and class I’ll explain:  Many of our patients have at least a sneaking suspicion that they are not people.  They look around the world and see others with the power and prestige and they compare that to the sense of emptiness and invisibility they feel.  Other people can go to parties, get married, work in the sciences, have children, buy houses, etc.  But they don’t see people like themselves prevailing in these areas.  As far as they knew, they were the only biracial kid in elementary school, adoptee in middle school, bisexual in high school, trans person in college, rape survivor at their workplace.

So if they feel that they’re worth a selfie, I join with them in celebrating themselves.

As their therapist I’d even have some questions:

  • What were you thinking and feeling that day you took this?
  • What do you hope this says about you?
  • What do you hope this hides about you?
  • Who have you shared this with?
  • What was their response?
  • What might this selfie tell us about who you are?
  • What might this selfie tell us about who you wish to be?
  • Where does that spark of belief that you are worth seeing reside?

In addition to exploring, patients may find it a useful intervention to keep links to certain selfies which evoke certain self-concept and affect states.  That way, if they need a shift in perspective or affect regulation they can access immediately a powerful visual reminder which says “This is possible for you.”

Human beings choose to represent themselves in a variety of ways, consciously and unconsciously.  They can be whimsical, professional, casual, friendly, provocative, erotic, aggressive, acerbic, delightful.  Are they projections of our idealized self?  Absolutely.  Are they revelatory of our actual self? Probably.  They explain nothing, acknowledge the person who takes them, and celebrate a great deal.  If there is a way you can communicate a willingness see your patient’s selfies you might be surprised at what opens up in the therapy for you both.

 

Melanie Sage, Assistant Professor, University of North Dakota

Melanie Sage, Assistant Professor, University of North Dakota

 

In other posts I have written about Huizinga’s concept of play.  Rather than as seeing selfies as the latest sign that we are going to hell in a narcissistic handbasket, what if we looked at the selfie as a form of play? Selfies invite us in to the play element in the other’s life, they are not “real” life but free and unbounded.  They allow each of us to transcend the ordinary for a moment in time, to celebrate the self, and share with a larger community as a form of infinite game.

It may beyond any of us to live up to the ideal that no one is less interesting than anyone else in our everyday, but seen in this light the selfie is a renunciation of the cynicism I sometimes see by the mental health professionals I meet.  We sometimes seem to privilege despair as somehow more meaningful and true than joy and celebration, but aren’t both essential parts of the human condition?  So if you are a psychotherapist or psychoeducator, heed my words:  The Depth Police aren’t going to come and take your license away, so go out and snap a selfie while everyone is looking.

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Breaking Eggs and Holding Your Fire: Some Thoughts on Skills Acquisition

August 14, 2013 by Leave a Comment

cod-sniper

Not too long ago, I was learning how to fire a sniper rifle in Call of Duty. It wasn’t going very well. I kept firing (which you do by holding down the right-hand trigger) and missing. Or I would use the scope, which you do by holding down the left-hand trigger; and then try to find my target so slowly that I’d get shot long before seeing it. To make thing more complicated, my patient Gordon** was trying to teach me the difference between “hardscoping” which meant to press and hold down the left trigger, and “quickscoping” which was more like a quick tap and release of the scope.

The key to success, I was told, was to locate the target, quickscope it for a second to take aim, and then fire. The source of my failure was that I’d see the target and not bother to scope at all, and just fire. At first I didn’t even know I was doing that. I thought the scope was going up, and it was, but it was going up a split second after I was firing and not before.  After several fumbled attempts Gordon said, “you have to not fire and learn to push the scope first instead.”  I suddenly realized that he was teaching me about impulse control.

Because many parents and therapists are reluctant to play video games, in particular first-person-shooters, they only tend to see them from outside the experience.  What they learn from seeing that way is that FPS are full of violence, mayhem, blood and noise.  Is it any wonder then that they grow concerned about aggression and the graphic nature of the game?  It’s all that is really available to them unless there is a strong plot line and they stick around for that.

But as someone who has been playing video games for years I can tell you things are different from within the experience.  And one of the most counterintuitive things I can tell you from my experience is this: First Person Shooters can help you learn impulse control.  It takes a lot more impulse control to not fire at a target the second you see it.  It takes a lot more impulse control to wait and scope.  And because all of these microdecisions and actions take place within the player’s mind and the game experience, outside observers see violence and aggression alone and overlook the small acts of impulse control the player has to exert over and over again.

Any therapist who has worked with adolescents, people with ADHD, personality disorders and a host of other patient types understands the importance of learning impulse control. That act of mindfulness, that ability to create a moment’s space between the situation and the patient’s reaction to it is necessary to help people do everything from their homework to suicide prevention.  In addition, there is always a body-based aspect to impulse control, however brief or small, and so to create that space is to forge a new and wider relationship between mind and body.

All of this was going on as we were playing Xbox. Over and over again, I was developing, practicing impulse control from behind that virtual sniper rifle.  Again and again I was trying to recalibrate my bodily reflexes and sensations to a new mental model.  Don’t fire.  When my kill score began to rise, it wasn’t because my aim had gotten better, it was because my impulse control had.

Meanwhile, for the past two weeks I have been practicing making omeletes.

In particular, I have been learning how to make an omelette roulée of the kind Julia Childs makes below (you can skip to 3:30 if you want to go right to the pan.)

This type of omelette requires the ability to quickly (in 20-30 seconds) tilt and jerk the pan towards you multiple times, and then tilting the pan even more to flip it.  Doing this over the highest heat the movement needs to be quick and reflexive or you end up tossing a scrambled eggy mess onto the burner.  I can’t tell you how tense that moment is when the butter is ready and you know that once you pour in the egg mixture there is no going back.  To jerk the pan sharply towards you at a tilt seems so counterintuitive, and this is an act of dexterity, meaning that your body is very involved.

In a way an omelette roulée requires impulse control just like Call of Duty in order to learn how to not push the pan but pull it toward you first.  But just as importantly, making this omelette requires the ability to take risks.  It can be scary to make a mess, what happens if the eggs fly into the gas flame?!

Let me tell you, because I now know what happens:  You turn off the flame, wait a minute and wipe off the messy burner.  And then you try again.

Adolescents, all people really, need to master both of these skills of impulse control and risk-taking.  To do so means widening the space in your mind between situation and action, but not let that space become a gaping chasm impossible to cross.  Learning impulse control also happens within experience, not in a special pocket universe somewhere apart from it.  Learning risk-taking requires the same.  And at their core they are bodily experiences, which may be what Freud meant when he said that the ego was first and foremost a body ego.

When I worked in special education settings, I was often called on to restrain children in crisis.  Afterwards we would usually do a postvention: “What was happening?” “How could you do things differently next time?”  We were looking at their experience from the outside, constructing a little pocket universe with words, as if we understood what had been going on in the experience, in the body and psyche of the child.  I doubt these post-mortems taught impulse control.

I wonder what might have happened if we had risked throwing some eggs on the fire and encouraged the kids to play first person shooters or other video games.  If my theory is right, then we would have been cooking.

**Not his real name. Name, age, gender and other identifying information have been altered to preserve confidentiality.

Mike is on vacation until September, which means that he has started talking in the third person at the end of blog posts.  It also means that the next new post will be next month.  He’ll repost an old fave or book excerpt to tide you over in the meantime.

 

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

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Empathy (Re)Training

June 8, 2013 by 2 Comments

 

2013.06.08.01.16.34

Last night I was mining Gold Omber in the asteroid belt near Erindur VI, and I can’t begin to tell you what an accomplishment that was. (This post is not just about spaceships, but about pacifists, Ethiopia and education, so non-gaming educators and therapists keep reading.)  OK, let me tell you why it was an accomplishment.  I am talking about playing the MMO EVE Online, which involves piloting spaceships across vast amounts of space in order to mine, trade, build or pirate among other things.  In essence, your spaceship is your character, with the ship’s parts being the equivalent of your armor and weapons in games like World of Warcraft.  But you can only build or use these parts as your pilot acquires skills, ranging from engineering to planetology to cybernetics, so in that way the player’s pilot is the character in the game.  But at the start of the game you’re told that the pilot is actually a clone (this becomes important later on) and as someone was explaining to me last night the whole cloning thing has its own complications once you start using implants to modify individual clones, which you can only do after you’ve trained the skill of Cybernetics.  And why all that is important is because once you use implants you can learn skills more quickly.

If you think that is confusing, try learning how to use the sprawling user interface or UI, which one of my friends says “was made by demons who hate people, hate their hopes and dreams. Know that you are playing with toys made by demons for their amusement and tread lightly.”  Another way of putting it is that you have keep trying to remember what window you opened in the game to do what, and often have multiple windows open simultaneously in order to figure out what you’re doing or buying or training.  There is a robot tutorial program in the game that helps somewhat, but the whole thing is very frustrating and intriguing for the first several hours of game play.  During this time I was ganked repeatedly, lost lots of loot and ore I had mined, as well as a nice spaceship or two.  So to get to the point where I had learned enough skills to be able to warp halfway across the galaxy, lock onto an asteroid, orbit and mine it while defending myself from marauders was extremely exciting.  I was only able to do this because my above-mentioned friend had given me a much bigger and safer ship than I had started out with, as well as lots of instructions on how to do things; and because I was chatting with people in the game who offered great tips.  Of course one of those people then clicked on my profile in chat to then locate me and gank me again (bye-bye nice ship,) but the knowledge is mine to keep.

By now you may be asking “what has any of this got to do with psychotherapy, social work or education?” so I’ll explain.  I had tried EVE months ago, and given up after about a week of on and off attempts, but this past month I have begun teaching an online course for college educators and MSWs about integrating technology into psychotherapy and education.  One of the required exercises in the course is for the students to get a trial account of World of Warcraft and level a character to 20.  There has been a lot of good-natured reluctance and resistance to doing this, in this class and others:  I have been asked to justify this course material in a way I have never had to justify other learning materials to students.   This included several objecting to playing the game because of violent content prior to playing it much or at all.  It’s as if people were not initially able to perceive the course material of World of Warcraft as being in the same oeuvre as required readings or videos.  It is one thing to bring up in your English literature class that you found the violence in “Ivanhoe” or the sex in “The Monk” objectionable after reading it, but I’ve not heard of cases where students have refused to read these books for class based on those objections.  So I was curious, what made video games so different in people’s minds?

Things became easier for several folks after I set up times to meet them in the game world, and help them learn and play through the first few quests.  As I chatted with them and tried to explain the basic game mechanics I realized that I had learned to take for granted certain knowledge and skills, such as running, jumping, and clicking on characters to speak with them.  I started to suspect that the resistance to playing these games was perhaps connected to the tremendous amount of learning that was having to go on in order to even begin to play the game.  In literacy education circles we would call this  learning pre-readiness skills.  Being thrown into a learning environment in front of peers and your instructor was unsettling, immediate, and potentially embarrassing.  And I think being educators may have actually made this even harder.  Education in the dominant paradigm of the 20th and 21st century seeks to create literary critics and professors as the ultimate outcome of education, according to Ken Robinson.  So here are a group of people who have excelled at reading and writing suddenly being asked to learn and develop an entirely new and different skill set within the framework of a college course:  Of course they were frustrated.

So I started playing EVE again not just to have fun, but to have a little refresher course in empathy.  I have leveled to 90 in WoW, so I know how to do things there, and had begun to forget how frustrating and bewildering learning new games can be.  In EVE I have been clueless and failing repeatedly, and getting in touch with how frustrating that learning curve can be.  I have also been re-experiencing how thrilling it is the first time I make a connection between too concepts or actions in the game:  When I realized that there was a difference between my “Assets” and my “Inventory” I wanted to shout it from the rooftops.  I have begun to see and help my students reflect on similar “learning rushes” when they get them as well.  They are now , in short, rocking the house in Azeroth.

We forget how thrilling and confusing it can be to learn sometimes, especially to the large population on the planet that doesn’t necessarily want to be a college professor or psychotherapist.  We forget that our patients and students are asked to master these frustrations and resistances every day with little notice or credit.

There is a village in Ethiopia, where 20 children were given Xoom tablet computers last year.  The researchers/founders of One Laptop Per Child dropped them off in boxes to these children, who had never learned to read or write.  They were offered no instruction and the only restriction placed on the tablet was to disable the camera.  Within minutes the children had opened the box and learned how to turn the computers on; within weeks they were learning their ABCs and writing; and within months they had learned how to hack into the tablet and turn the camera back on, all without teachers.  This story inspires and terrifies many.  It is inspiring in that it tells the story of what children can learn if they are allowed to be experimental and playful.  It is terrifying because if all this was done without a teacher to lecture or a therapist to raise self-esteem, it raises the question “do we still need them?”

Having played EVE, and taught academics in World of Warcraft, let me assure you that the world still needs teachers and therapists.  But the world needs us to begin to learn how to teach and help in a different way.  If EVE had nothing but online tutorials I would have probably struggled more and given up.  I needed to remain social and related to ask for help, listen to tips, and get the occasional leg up.  We need to retrain ourselves in empathic attunement by going to the places that scare or frustrate us, even if those places are video games.  The relationship is still important; to inspire, encourage and enjoy when learning happens in its myriad forms.  But we need to remember that there are many literacies and that not all human beings aspire to teach an infinitely recurring scholasticism to others.  We need to remember how embarrassing it can be to “not get it,” and how the people we work with every day are heroic that they can continue to show up to live and be educated in a system that humiliates them.

What’s exciting and promising, though, is this simple fact:  Learning is happening everywhere, all the time!  Whether it’s a village in Ethiopia, Elwynn Forest in Azeroth, or in orbit around Erindur VI; learning is happening.  Across worlds real and imagined, rich and poor, learning IS happening.

And we get to keep all the knowledge we find.

 

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What To Do When Your Therapist Turns Into A Kitten

May 1, 2013 by 10 Comments

kitten

I have been working with patients online for about 6 years, and even now I have some interesting surprises in the work.  Recently I was meeting online with one of my long-term patients for their regular session.  I use my laptop but have a better web camera and monitor hooked up to it.  The bigger monitor allows me to see the patient’s image, but also keep an eye on my image so I can see what the patient is seeing.  The laptop monitor stays dark, and the laptop’s built-in webcam goes unused, at least most of the time.  But this particular day the laptop webcam decided to switch on 15 minutes into the appointment, and hijacked the webcam I was using.  So from what my patient could see, one minute I was there listening empathically, and the next minute I had disappeared.

Those of you who enjoy object relations theory should be enjoying this story by now.  Wait, it gets better.

As I was explaining to my patient why I’d disappeared, I was trying to turn off the laptop’s built-in webcam.  Instead I turned on a special program the laptop has that replaces the screen with the image of a kitten, the one seen above in fact.  Suddenly I was not invisible, but a kitten.  Better yet, the kitten was lip synching and moving its mouth when I spoke.  Fortunately this wasn’t happening at a particularly delicate moment in the therapy, and we both had a good laugh at it.  I apologized to my patient and said, “you know, I studied a lot of things at grad school, but they never taught me what I’m supposed to do if I turn into a kitten when I’m with a patient.”

Many psychotherapists have the sort of relationship with technology that resembles the folks they treat with Borderline Personality Disorder:  They alternately overidealize and devalue tech, often in the same breath.  “Skype” will be the way we salvage our dwindling practices, we’ll be able to reach people all over the planet, make our own hours and go completely self-pay because most insurance doesn’t cover it.  It will be wonderful.  That’s the overidealizing part, the devaluing part is more subtle.

Because I do a growing amount of therapy and supervision online, I often get requests for a consultation session to help therapists who want to do online therapy and “need my help getting on Skype.”  At this point I try to explain that Skype is not HIPAA-compliant, and that there is more to it that getting a webcam, but here’s where the devaluing of technology comes in.  It’s as if some folks think that the only thing one needs to know in order to be an online therapist is how to download a program and turn on the camera.

Most therapists who decide to get Basic EMDR training wouldn’t bat an eye at needing to go through two weekend trainings and a minimum of 20 didactic and 20 hours of supervised practice in order to be certified.  And yet many therapists don’t consider that working online and with emerging technologies requires more than learning how to flick a switch.  It’s sort of the way people often treat the IT guy at the workplace:  With one breath we describe ourselves to him as “clueless” about technology; and yet we really want him to stay in that basement office until we need him to come up and fix our email.

Graduate programs teach us next to nothing about how to use technology in our practice, except perhaps to warn us to avoid it at all costs.  Think about it.  Do you know what to do if you disappear in the middle of talking with a patient?  Do you know what to do if you turn into a talking kitten?  More importantly do you know how to prevent yourself from turning into a talking kitten, or turn yourself back from one if you do?  And perhaps most importantly, do you know how to help patients anticipate the glitches with virtual therapy, process the unique empathic failures that can arise, and create a good-enough holding environment online?

People like my colleagues DeeAnna Merz-Nagel and Kate Anthony founded the Online Therapy Institute for just this reason.  They offer dozens of different 5 hour courses on various technologies, from video conferencing to text chat to conducting therapy in virtual realities like Second Life.  The takeaway here is that there is a lot more to learn about online therapy than downloading Skype.

Look, I am not trying to discourage people from doing online therapy, in fact the opposite.  I know that it can be a very effective treatment modality, and easily accessed by a growing global population.  I’m not even trying to get you to sign up for consultation with OTI or me or anyone in particular.  The point I am trying to make is that it is an additional skill set that needs to be learned and integrated into your clinical repertoire.

Psychotherapists don’t just buy chairs and a couch and start talking.  EMDR isn’t just wiggling your fingers in traumatized people’s eyes. Both take time, case supervision and specialized training.

Online therapy, and integrating social technologies into your therapy practice is no different.

 

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Nice Everything You Have There: Mindful Minecraft

March 13, 2013 by 4 Comments

2013-03-08_22.06.42

Did you know that Minecraft has a lot to teach us about how we pay attention to, get distracted from, and cope with things? Embedded in the design and the lore of the game are nuggets of philosophy, neuroscience, and psychology. From work/life balance to physical and mental health to the meaning of life Minecraft has something to teach us.

That’s why I decided to present on mindfulness and Minecraft this year at SXSW.  If you were there, thanks for coming, but if you weren’t fret not, for David Smith of Austin, TX was kind enough to videotape the event on his iPhone.  David, thanks for your stamina!  The video is broken into 5 parts, and I’ll include the prezi for you to play with as well:

 

 

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Avatars & The Curated Self

November 25, 2012 by 2 Comments

If I ever meet James Cameron, I hope I will remember to ask him if it was a coincidence that he chose to the make the aliens blue.  His movie, Avatar, garnered 3 Academy Awards for it’s epic tale of humanity’s encounter with the Na’Vi, largely through the creation of avatars, body forms that humans beam their consciousness into so they can mingle and fraternize with the locals.

The concept of the avatar comes originally from Hinduism, and refers to the concept of a God or Supreme Being deliberately descending to earth in a manifest form.  One of the most popular gods for doing this is Vishnu, also blue.  The concept of avatar in  Hinduism is more complicated than this, but the piece of it that pertains to this post is the general concept of the attempt of a supreme being to incarnate part of itself to enter the world.  There is an inherent diminution or derivative quality to it.

If you are more familiar with video games than Hinduism, you are probably more familiar with the concept of an avatar meaning the graphical representation of the player’s character in the game.  When we play Pac-Man, our avatar manifests in the video game as a little yellow circle with a mouth that races around gobbling dots.  Over the decades games and graphics have become capable of more sophisticated avatars ranging from the Viking-like Nords of Skyrim to the soldiers of Call Of Duty.  As these video game worlds proliferate, players descend into them with avatars of many shapes, sizes and species.  Some games, like Eve Online, allow you to customize the features of your avatar extensively; others allow you to pick from a limited number.  We are always diminished by the process of taking on an avatar.  Even if the powers an avatar has in the video game world are immense, it is derivative of the complexity of being human.

What is interesting is that most of us use avatars every day online, we just never realize it.  Video games are just one form of social media, and avatars abound in all of them.  The graphic may be as simple as our picture next to a blog post or comment, or a video on Youtube.  But in the 21st century most of us are digital citizens and use one form of avatar or another.  Some people in the world will only ever know us through our avatar in a video game or Second Life.  And yet we know something of each other.

I think more and more of us are becoming aware of the connection between the avatar and the curated self, the aspects of our psychological self we choose to represent online.  The curated self is the part of ourselves we have some ability to shape, by what we disclose, what graphics we choose, and how we respond to others.  Like an avatar, the curated self at its best is deliberate.  I say at its best, because although the curated self is in our care, we can also be careless with it.

Recently I posted a video of myself on my YouTube channel entitled “Should Therapists & Social Workers Post Videos Of Themselves On YouTube?”  In making the video I chose to wear a bike helmet, and by the end of the post was using the bike helmet as an example of the risks we take when we opt to attempt innovation of our curated self.  The video was designed to inspire critical discussion and thinking, and it did just that.  In some groups where it appeared people described the video and points it was illustrating as “brilliant.”  Other groups interpreted it as an instructional video on how to advertise your therapy practice and lambasted it.  There was a myriad of responses, and I’m sure even more from people who opted not to comment on it.  I received a number of likes of it, and a number of dislikes.

What I think is important and instructional here was how people began to comment through their avatars as if they were addressing the whole person I am rather than an avatar.  And they made incorrect assumptions ranging from my age to my motives.  The bike helmet and my posture on the video became the target for some incredible nastiness disguised as constructive criticism.  From the safety of their own avatars they hurled some invectives at who they thought I was and what they thought I was doing in front of an audience of other avatars who alternately joined in, were silent, emailed me privately to offer words of support, or publicly commented on what they saw.  The irony to me was that people began to demonstrate all of the roles we encounter in “cyberbullying,” which was part of what the video also touched on.  In a perhaps not surpising parallel process, we got to see and play out the sorts of dynamics that our patients and children experience all the time.

We need to remember that every avatar is a derivative of the person.  It is connected enough that we have attachments and responses to it.  We can feel proud or ashamed, hurt or healed through our avatars.  In fact, research from Nick Yee on “The Proteus Effect” has shown that playing a game with a powerful avatar for 90 seconds can give the player increased self-confidence that persists for up to 6 hours.  It stands to reason that if someone experiences their avatar as weak or socially unacceptable for a brief time there may be lasting effects as well.  Behind the guy in a bike helmet is someone else.  He may be a faculty member at Harvard, a sensitive fellow, a father, a student, a man who just lost his partner, a person with a criminal record, or any, all or none of these.  But he is always more than the derivative of his avatar.  We need to practice being mindful of this and model it as we train others to be digital citizens.  It is counterproductive to sound off on cyberbullying to our children or grandchildren, when they can Google us online and see us doing it ourselves.

We also need to help our patients, their families, and colleagues understand the active role we need to take in curating ourselves online.  We need to understand what may happen when we put certain things out there.  For therapists this includes the dilemma of putting out a curated self that resembles what kind of work you would do, while not disclosing or conveying more than you want the world to know.  The example I always use with students and consultees is how I talk about my family but never who they are in particular.  This is deliberate, because it is no big disclosure that I have a family, everyone on the planet has one of sorts with the possible exception of Dolly the cloned sheep.  But beyond that I curate a private self, and let folks project what they may.  If we put out comments describing patients or coleagues as “screwed up,” we are also curating ourself, I suggest poorly.  We need to be mindful that most groups we participate online in are open and searchable.  Many of my colleagues became therapists at least in part because they didn’t want to be known and thought the best defense was a good offense (“We’re here to talk about you, not me.”)  They’re used to sharing the gallows humor with the team, and think the same applies to online.  I’m with Rilke on this one:  “for here there is no place/that does not see you. You must change your life.”

To paraphrase Wittgenstein, “our self is everything that is the case,”  not just one avatar, blog, string of emails or video; not even the composite of all of them.  Nor is our curated self everything that is the case.  We’re more than our Facebook likes or our Twitter following.  Human beings are so much more, much more wondrous and tragic than the curated self.  We descend into the Internet and are diminished, but do bring some deliberate part of ourselves along.  We will only ever know hints and glimmers of ourselves and each other online.  As for the rest:

“Whereof one cannot speak, thereof one must be silent.” –Wittgenstein

 

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What Do Gamers & Social Workers Have In Common?

January 22, 2011 by 16 Comments

The Dutch cultural theorist and early scholar of ludic studies Johan Huizinga took play very seriously.  Gamers and Social Workers alike would have loved Johan–he spoke out against Nazism and German influence on Dutch Science in 1942 at a lecture he gave.  This was not the first time he had done so.  As early as 1935 he had grown alarmed at the rise of fascism and written, “We live in a demened world, and we know it.”  By 1942, his speaking truth to power had finally gone too far in Nazi estimations, and he was imprisoned, then detained, by the Nazis in the village of De Steeg.  He died there 3 years later.

It was during these final years of his life that he refined and wrote his book, Homo Ludens, which translates to “Man the Player.”  In this book he explored the serious nature of play as a cultural phenomenon present in art, war, and politics.

Huizinga determined that play has 5 essential elements, to which I add examples as appropriate to gaming and/or social work:

  1. Play is free, is in fact freedom. When we are playing, we are not doing it for any other reason than that we want to.  Play to be play must be a voluntary activity that we initiate or accept the invitation to enter into ourselves.  In that regard you could say that play is always an assertion of the self, and free will.  We gamers choose to spend our time gaming, choose one game over the other.  This is why gaming as play does not adhere to the slavish concept of addiction.
  2. Play is not “ordinary” or “real” life. What makes play so much fun, and so important is specifically that is isn’t bounded by the realities of daily living.  It is pretend, and extraordinary, and it allows us to escape real life.  But this is exactly why gamers and other people who play aren’t psychotic.  We may talk about the games we play to lengths that bore or disturb others, but we know that games are apart from real life.  That’s what makes them fun!  I may hurl arcane energy at a dragon in WoW, but I am aware (albeit sadly at times) that if I ever encounter a dragon in real life I will not be able to summon magic at my whim to destroy it.  And that is why Second Life is not called First Life.  For play to be play, we have to know we are taking ourselves out of the real world to participate in something else.
  3. Play is distinct from “ordinary” life both as to locality and duration. When I get ready to play WoW,  I sit down or stand at my computer; but when I play I am in Azeroth.  Whether it is chess, poker or a video game, the play experience takes place in another time and space, and it has a beginning and an end.  Even MMORPGs, which push the last quality in some ways, have an end for individual players, when we cease participating in the game world for the time being and resume the activities of daily living that await us in the real world.
  4. Play creates order, is order. Play demands order absolute and supreme. By this Huizinga meant that for play to work it needs to have rules as well as time and space boundaries.  We all know how to play Hide and Seek, the next time you play it try being the “Seeker” and go hide along with everyone else; or come out of hiding and start chasing the Seeker.  Bizarre and funny, but the game won’t be Hide and Seek anymore–Tag, maybe, but then we’ll know that something has fundamentally changed.  And in World of Warcraft everyone needs the same amount of experience points to get to level 80, and we expect the griffin flight paths to always stop in the same places.  Wizards will never wear plate mail and hunters can’t teleport.  That’s just the way things are, that’s the order of things.
  5. Play is connected with no material interest, and no profit can be gained from it. Ask any gold farmer around the world, and they will tell you that there is a big difference between playing WoW and logging in to the game to make and then sell money.  Gold selling can’t even happen entirely in-game, and Blizzard bans it for good reason.  It’s cheating, not serious play.  The loot items that I “get” in the game aren’t things I can profit from in the real world.  I can’t take my Corp’rethar Ceremonial Crown with me when I leave the game, which is why I would be so useless if a dragon shows up in Harvard Square.  And although Second Life has a different approach, allowing you to buy in-world “Lindens” for real-world monies, I’d suggest that the act of buying the Lindens occurs outside the play experience:  Sigmund Steampunk isn’t buying Lindens, Mike is buying Lindens “out here” and sending them to Sigmund “in there.”

So what’s all this got to do with gamers and social workers?  Lots!  Both gamers and social workers value freedom a great deal for starters.  And social workers (I am saying social workers, but this applies to all psychotherapists) understand that therapy, like gaming, is a form of play.  We experience more freedom to explore and express our internal world in therapy.  It happens at a given time and place, even as an online event.  What happens inside the therapy, a la Winnicott’s “Transitional Phenomenon,”  is both alike and different from the “real world.”  And there is order in therapy, some firm rules and limits in terms of what can or should happen in it.

As for the money bit, I would suggest that if we lived in a culture where capitalism was not the norm, the same parts of therapy that are so powerful and rewarding, the play-elements, would still be as powerful.  Another way of looking at this is to ask yourself if you conduct therapy any differently with patients who are on Medicaid than those who are private pay?  I’m not talking about feeling annoyed that you aren’t getting paid well, but the game you play.  Do you only think psychodynamically with your private patients?  Do you change the boundaries when its Medicaid?  Or do you try your best to do what’s best for each patient regardless of the payment?

And as social workers, don’t you advocate for others with the powers that be in ways that are not connected with your material interest?  Take Civil Rights, for example.  The years and years of advocating, protesting and legislating are not something that the social workers involved derived a profit from.  In fact that is what makes our endurance in fighting for social justice so admirable.

This is why many gamers will make excellent social workers, by the way.  Gamers are experts at endurance.  That guy in your office that seems like a “slacker” actually has more in common with you than you think.  He has spent hours trying to down the Lich King–trying and failing, and then trying again.  He has spent hours researching strategies to work as part of a team and not given up.  Jane McGonigal pointed out recently on NPR that majority of time gamers are online, they are failing to accomplish their tasks.  That’s why it is so admirable that they keep at it.   So yes the adolescent you’re sitting with may have grades that are plummeting in school, but don’t blame the games!  Try instead to harness that discipline, focus and stamina by exploring how it shows up in-game, and then how it can be used to change his real life.

And the connection between gaming and social justice isn’t as far-fetched as you may think:  A 2009 Pew presentation from Amanda Lenhart showed that 49% of teen gamers reported seeing people being “hateful, racist or sexist” while playing– which means that they can identify hate, sexism and racism.  What’s more, three-quarters of these kids reported seeing other players regularly respond to such behavior to confront it.  That’s a hell of a lot better than most high schools and college campuses are doing these days!

So gamers and social workers both understand the value and seriousness of play, as an imagined space in therapy or in Azeroth.  Gamers and social workers both understand the value of psychic change and social activism.  And gamers and social workers alike regularly demonstrate hard work and stamina in the face of dragons and fascism.

Johan Huizinga would be proud.

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Virtual Worlds, Real Feelings

January 14, 2011 by 14 Comments

When psychotherapists begin working with gamers and exploring their in-world experience, it can be a bit overwhelming.  So much new language, 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’ve often encouraged therapists to take the time to use the free trial membership on WoW or other games in order to immerse yourself 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.

Let me give you a real-life, non-game example to start.  I went to Connecticut College with my friend and colleague Susan Giurleo (she’d never say this, but Susan was definitely the more organized one in college 🙂 ) and we went on to live the next two decades with no real contact.  And then Twitter stepped in, and we resumed contact.  When I read her blogs and posts I was happy to discover that we had a lot of similar and overlapping interests.  We made a time to meet for coffee via email, and I was excited and nervous to see her for the first time in a long while.  Those feelings, of happiness, discovery, excitement and nervousness were all real feelings happening in real time to a real person via a virtual world.  We’d reunited virtually and this has had a real and positive emotional impact on me.

You may still be inclined to dismiss the emotional impact of virtual worlds.  “Sure, Mike, you had real feelings, but Susan was a real person that you have had real face-to-face contact with in the past.”  So let me give you another example.  I recently had the opportunity to email Chris Brogan, and in the course of that mentioned my knowing Susan.  Shortly after that I “heard” them talking about me on Twitter:

from @susangiurleo @chrisbrogan So glad you met my friend, @MikeLICSW ! RT Gamers meet therapy – http://ow.ly/3DT0A

@ chrisbrogan @susangiurleo – yep, loved what he shared. That @MikeLICSW is a nice fellow.

Two lines of Twitter, and as I read them I noticed myself smiling, well actually beaming.  That’s real pleasure I was feeling, from feeling recognized and introduced.  And I’ve never laid eyes on Chris in the virtual world.

So virtual worlds create real feelings, and we need to remember that when working with gamers.

I’ve written before about the face behind the screen but it bears repeating.  Gamers are people, and they have feelings.  Even if the stereotypes were true (and they’re not) that 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 need to pay attention to them.

So do you ask adolescents about their facebook friends as well as their classmates?  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.

The next time you are checking out Facebook and see an old friend, or read a political post, notice if you are feeling happiness, excitement or anger.

The ask yourself, can I tell the difference between this and a “real” feeling.

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Want to Change a Behavior AND Feel Heroic? There’s an App for That…

December 28, 2010 by 7 Comments

Click to See Looty Goodness!

 

I must confess I am not a big one for New Year’s resolutions. I rationalize this by saying that one should change one’s behavior when insight hits, not wait for a specific date. The truth is, like many of you, I want to avoid change, even if I know it is good for me. But if there is one thing that can motivate me to do something, it is “epic loot.”

In gamer parlance, “loot” is the general term for specific prizes you win in-game by completing a quest or downing a boss. In World of Warcraft the loot is color coded. White labeled loot is “common;” “uncommon” loot is green; “rare loot” is blue; and “epic” loot is purple. Recently we all had to say goodbye to our Epic armor and weapons, because the Cataclysm expansion introduced a higher level and item level. But I digress.

Token economies and reinforcement are nothing new to the field of psychology and the practice of behavioral modification. But now, if you or someone you know is a gamer, there is a way to tap into this love of loot and leveling up in the out-of-game daily life. It is a new App for the iPhone (sorry Droid, you fail!) and it is called Epic Win.  (Thanks to @DorleeM on Twitter for tweeting this to my attention– follow her, she knows stuff.) This fun little app can be programmed with your list of to-dos.  You choose your starting avatar, such as a Dwarf, Warrior Princess, or Skeleton.  Then you enter the tasks you want to do.

You assign each task with a amount of experience points, and when you complete it you see a graphic of your character and a sound effect as you gain the points.  Enough points and you level up, which also brings you loot, and you can see yourself progressing across the map of a Middle-Earth-like world towards your next loot.  Ominous music and drum beats remind you that you are on a quest of great importance.  You can measure your progress in miles as well as points, and the graphics and humor in the App are quite compelling.

To start with I chose two tasks that I wanted help and encouragement with:  blog entries and my weekly run around Fresh Pond.  I picked these because they are also recurring events, and I programmed the App to have them recur weekly and monthly, and to sound a little alarm to remind me to do them.  To see how this would work (and give me some credit to level up!) I backdated my running for this month.  After accomplishing these “quests” I was able to advance to level 2, and I received my first piece of loot, a “Tatty Wooden Chalice.”  Humble beginnings, but it had a funny caption to go with it:  “Yes it leaks, yes you get the occasional lip splinter, but it’s still better than cupping your hands.”  The humor, sound effects and getting a prize all make it easier for me to stay motivated.

You can name your own avatar or the App will assign you one.  I liked the one my Skelly got, and so I am keeping “Calcium Facebone” for the time being.  As I have written previously, we often form attachments to our avatars, and this combined with the achievement of measurable goals and the heroic sense of being on a quest add up to behavior modification with a chance of succeeding.  Calcium and I have already traveled many miles together (140 to be exact,) and collected 190 gold.  And after I post this blog entry, the 100 points I get will porbably bring me to my next piece of loot.

I can’t wait to see what it is.

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