Interview: DeeAnna Merz Nagel of the Online Therapy Institute

DeeAnna Merz Nagel is co-founder of the Online Therapy Institute and author of Therapy Online: A Practical Guide.  She talked to WTCI (online, via email) about how she became an online therapy guru and the why/how of doing therapy online.

What is your background?

Educationally, I am trained as a rehabilitation counselor. I received an M.Ed. in Rehabilitation Counseling from the University of Georgia in 1994. Prior to that, I worked in the field of mental health and human services for 5 years. After I completed graduate school I received post-graduate supervision and training working with adult survivors of sexual abuse. For several years following, I worked in many diverse settings- both urban and rural – helping people dealing with poverty, domestic violence, homelessness and developmental disabilities. I spent many years working with child welfare families and foster children offering in-home therapy to families and conducting forensic evaluations to the courts. I am a Licensed Professional Counselor in GA and NJ and a Licensed Mental Health Counselor in NY.

In 1999, I discovered the power of the internet while researching respiratory symptoms. I was sick and a diagnosis eluded my doctors. I turned to the internet for solutions and ultimately, support. I was finally able to talk with my doctor about what I had discovered through support forums and bulletin boards online and I was ultimately diagnosed with Sarcoidosis. From that point on, I realized the inevitable impact the Internet would have in the lives of people all over the world.

Around that time I began offering online counseling through an e-clinic. I joined the International Society for Mental Health Online and had the opportunity to be mentored by pioneers in the field. Eventually, my health improved and I joined the workforce full-time again. For the next 8 years I continued to offer online counseling to clients, maintaining a part-time practice online. In 2005 I was elected ISMHO’s president and I continued to network with my colleagues at conventions and conferences, meeting peer professionals in cyberspace and in person. Regardless of my “day job” online counseling remained my passion. I became a Distance Credentialed Counselor and transitioned from becoming certified to facilitating the DCC trainings. While running an in-home, community based mental health organization, I routinely conducted online field and clinical supervision with employees and contractors.

What do you do now?

Today almost all of my work is related to online therapy and the internet. I am the co-founder of the Online Therapy Institute with my colleague, Kate Anthony. We decided a couple of years ago that we wanted to bring our experience to as many people as possible. To that end, we co-authored a book, Therapy Online: A Practical Guide (just released!) and co-founded the Institute. We offer online training and consultation and promote social networking and the use of Web 2.0 as a way for mental health practitioners across the globe to connect and learn from one another. We offer many avenues for social networking, education and supervision about the impact of technology on mental health. Soon we will be launching a new series of offerings including training and marketing opportunities for OTI members.

I also maintain a small private practice in Atlantic Highlands, NJ and most of my clients deal with issues related to the internet, ranging from cyber affairs and compulsively surfing porn sites to understanding their teenager’s use of social networks like MySpace and Facebook. I spend a lot of time normalizing the internet for some, and teaching appropriate boundaries around the internet for others. Most of my in-person clients also see me online as adjunct to face-to-face sessions. I also conduct e-counseling through a major EAP organization in Canada and I continue to facilitate the Distance Credentialed Counselor training through ReadyMinds (www.readyminds.com).

For a licensed therapist interested in expanding to online services, what are the steps? Is coaching certification necessary? More insurance…?

A therapist or coach who is interested in expanding services to clients online is advised to seek additional training to increase competency. In a “buyer beware” world, it is encouraged that professionals demonstrate to their public that they have the necessary skill and training to conduct services online. At the Online Therapy Institute we offer ethical frameworks for mental health professionals and career and school guidance counselors. In the spring we will release an additional ethical framework for coaches. In January we are launching several online courses for mental health practitioners. For coaches who are also licensed, these courses will offer the necessary training to practice proficiently. Other trainings are becoming available across the globe and professional organizations such as the APA and ACA are offering sessions on topics about online therapy and the use of technology at annual conferences and conventions.

With regard to malpractice insurance, practitioners should check their coverage to ensure that online counseling is not excluded. The practitioner is advised to follow the laws of both the client’s geographic area as well as the laws of the practitioner’s geographic area. While the safest precaution would be to practice within state boundaries, if neither location restricts the practice of online counseling, then it might be presumed that it is safe to proceed. Even so, laws change rapidly and it is difficult to keep up-to-date. Practice due diligence by calling state licensing boards and checking the internet for state laws. OTI offers a Law and Ethics Wiki and we add information as it becomes available. Document efforts of discovery in the client’s file.

In OTI’s ethical framework for mental health, screening for clients who are not appropriate for insight-oriented therapy is advised–makes sense. What happens if an online therapy client emerges as being suicidal, substance abusing, in crisis, or otherwise not appropriate during the course of treatment?

Just as with face-to-face counseling, appropriate client screening is essential. This can occur via an initial consult online or via telephone. In addition, I use the same questionnaire with my face-to-face clients as I do with my online clients. I ask questions related to psychiatric history, medical issues, immediate concerns, medications and I ask about the client’s experience with technology. I state in my informed consent that the client and the therapist utilize the first couple of sessions to assess the client-therapist fit. With regard to crisis, as soon as I receive a new client, I research local resources, and police/fire numbers. Then I follow much the same protocol I have followed when working crisis hotlines. In fact, I encourage practitioners who want to work online to take a crisis hotline training through an agency in their local community, Hotlines have been doing crisis work for decades so handling crisis via distance is not a new concept. Of course, this protocol changes depending on the setting. For instance, the EAP I contract with offers 24/7 support through a crisis call center so the client has access to that number and from the beginning.

Other referrals for services such as substance abuse and psychiatric consults are made as necessary just as in face-to-face work. The key is knowing the client’s geographic area and having a comfort level with researching resources online and developing a peer professional network when such referrals are needed. Networking online is as important to the online therapist as networking within one’s local community for a face-to-face therapist.

Have there been nightmare scenario online therapy legal cases? How are courts weighing in on the subject (if at all)…?

I am not aware of any case law to date that is influencing online practice. But that is always subject to change! In my opinion, following state laws, avoiding dual relationships and maintaining confidentiality online are “hot spots” that could easily lead to legal trouble. All correspondence that would be considered part of the psychotherapy record should be encrypted and practitioners are wise to consider how they manage their online presence with clients given the advent of Web 2.0 and social media.

Any final words of wisdom for therapists interested in offering online services?

If you are interested in conducting online therapy or online coaching, educate yourself. The nuances online and with other forms of technology are real and as with anything we add to our intervention toolkit, we should be skilled and prepared while also working within our scope of practice. And remember, if you are a coach but you are also licensed as a mental health practitioner, your license is the standard of care to which you should adhere. I have spoken with many therapists who think that if they call themselves a coach, then they can avoid any liability that may come with conducting online therapy. That simply is not true.

I hope this is the decade that online therapy is embraced as a viable alternative for those who so choose. Telepsychiatry is already offered in rural communities across the country and now the military is offering online therapy through TriCare. Employee Assistance Programs are offering online interventions and the research is showing efficacy in online methods of delivery. The time is now. We are no longer asking “Should we offer online therapy?” We are now asking, “How do we offer online therapy?”

If you are interested in continuing this dialogue and other similar conversations, join us at www.onlinetherapysocialnetwork.com! We would love to have you!

Find DeeAnna Merz Nagel online at www.deeannamerznagel.com and www.onlinetherapyinstitute.com