Health Beyond 2009 – e-health, Serious Games and Second Life

Posted originally over on Metaverse Health:

As a Registered Nurse with a passion for the use of emerging technologies to improve health, it can sometimes be a little frustrating when things don’t seem to progress as fast as one would like. There’s also the ‘they just don’t get it’ phenomenon amongst some in health leadership and management roles, which can lead to the conclusion that progress is all too slow with new approaches.

A stark contrast to that is occurring this week in Melbourne, Australia, with the HealthBeyond e-health Consumer Day. I was very happy to be invited to attend this event to provide participants with a tour of some key health presences in Second Life in conjunction with what will no doubt be an engaging keynote from Mandy Salomon . It’ll be difficult to choose which health areas in Second Life with so many great options, but I do know the University of Plymouth’s sexual health sim is going to feature.

It’s great to see the Health Informatics Society of Australia taking such a lead, featuring virtual worlds, serious games for health and broader gaming for exercise and stimulation in a get-together of this calibre. I have a feeling there’s going to be some exciting announcements come out of the gathering for the Australian health sector, which I’ll report on in coming weeks.

Popularity: 3% [?]

Interview – DeeAnna Nagel and Kate Anthony, Online Therapy Institute

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?

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 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.

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 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.

Popularity: 5% [?]

PIVOTE – open source learning for virtual worlds

British firm Daden have been releasing virtual worlds products for a while now – we covered their in-world web browser last July. Their latest launch is an “open-source learning system or virtual worlds, the web and iPhone”. Its moniker is PIVOTE and it’s the result of a project called PREVIEW funded by the UK Government’s Joint Information Systems Committee (JISC). The project’s focus was problem-based learning in virtual worlds, and PIVOTE is the end-result. Paramedic training for St George’s, University of London was the initial focus that’s led to final product.

Essentially, Pivote is a web-based learning management system where detailed exercises can be formulated as fairly standard, text-driven scenarios with decision pathways, or as avatar driven exercises in Second Life or OpenSim (Daden states its platform can easily be adapted to other virtual worlds). The text-based options can also be utilised in-world via what is presumably Daden’s in-world browser. St George’s have a sim in Second Life (click here to see for yourself) that is publicly accessible.

St George’s Senior Lecturer in Paramedic Science, Alan Rice said “This programme provides the students with a fun learning environment, where they can afford to make mistakes online, which they could not afford to make in the real world. When they make a mistake online, they are always keen not to make the same mistake again.” A paramedic student at St George’s, Fiona Cropp, was happy with the virtual training process – “It’s a really useful tool. It’s much better to be able to actually perform treatments rather than just talk about it. Everyone is online at the same time so you can bounce ideas off each other and make an informed decision. I had never used Second Life before, but I found it really easy to get on with.”

A useful overview of the paramedic training scenario can be viewed here:

Pivote isn’t the first integrated training solution using virtual worlds, but it’s certainly progressed things considerably. The challenge for any platform is convincing key management that scarce health dollars should be sunk into virtual worlds-based training. Health professionals and academics are perfectly positioned to demonstrate just that, and there’s no shortage of evidence of the cost benefits of effectively trained clinicians. Anything that increases the confidence of new practitioners in the breadth of the clinical decision-making in a cost-effective way, will surely gain some traction in what is usually a very conservative space.

Anyone wanting to install PIVOTE for themselves can do so for free by installing it on their own servers or paying Daden to host it for them. The full instructions can be found by browsing the ‘Getting Started’ section of the PIVOTE website.

Popularity: 7% [?]

Relay for Life in Second Life: teams being formed

A yearly highlight in Second Life is the American Cancer Society’s Relay for Life. The 2007 and 2008 events were big successes, with more than 55 million Linden Dollars (approximately 200 thousand US dollars).

Teams have started forming and if any Australian or New Zealand teams are forming, do let us know and we’ll promote your fundraising efforts. The team registration form can be found here.

The Australian Relay for Life is a superb community event for a lot of towns and cities. The Second Life version achieves that same community vibe and it’s an opportunity to remember those lost to cancer, to support those currently fighting cancer and to help find more effective treatments for cancers.

Thanks to SL Entrepreneur Magazine for the heads-up.

Popularity: 6% [?]

Therapy and the metaverse

Mark Kizelshteyn (SL: Chronos Laval) is a virtual world researcher and one of two principals at virtual worlds developer Popcha!. As part of his recent university studies he completed a paper called Therapy and The Metaverse: Second Life and The Changing Conditions of Therapy For Convalescent and Chronically Ill Users, which will be published in Washington University’s Undergraduate Research Digest – you can download the full article here.

Kizelshteyn will be discussing his work in Second Life on January 22nd between 1 and 2 pm SLT / PST (8am Friday 23rd January AEDST), with John Lester (Pathfinder Linden) launching proceedings. The venue will Popcha! headquarters. If you’d like to attend you’ll need to RSVP to Chronos Laval in Second Life. The paper itself is a useful overview of what virtual worlds like Second Life offer in regards to engagement, a sense of community and the ability to experience presence in ways that may not be feasible in real-life for people with chronic illnesses. The case study in the article (Amy the DJ) is well encapsulated and illustrates the power of the interaction in Second Life really well.

There’s no dearth of health research going on and even broad articles like this illustrate the depth of work going on. With virtual world development businesses realising the potential in the market, there’s also a growing realisation whilst that rigour in approach to development for health presences needs to mirror the discipline applied to health endeavours themselves.

Popularity: 5% [?]

Sexual expression in virtual worlds – is normalcy achievable?

From our sister site, Metaverse Health:

For many, the Christmas / New Year period is a time when there’s more regular social contact with people. It’s certainly been the case for me and it’s emphasised a well known virtual world conundrum – personal boundaries. Over the past month I’ve had the occasion to discuss virtual worlds with a handful of people who have no experience with them at all. In each case, the issue of virtual sex would arise – no surprise there. What did surprise me in its regularity in being raised, was the belief that real-world personal boundaries shouldn’t apply in virtual worlds.

One friend, who’s got a postgraduate education, said to me “if you can’t get immediate and free sex in Second Life, why would you bother?”

It’s not an uncommon opinion by any means. It actually sits on the opposite end of the continuum from “virtual sex is wrong / funny / worthy of ridicule”. In the middle is a limited amount of work being done by health professionals and educators on promoting sexual health, particularly in Second Life. Until there’s further work done in the area of establishing the ‘normalcy’ of sexual expression online (with the usual caveats around unacceptable behaviour / child pornography / extreme sexual violence etc), opinions like my friend’s will continue to hold sway. Some would argue that’s not necessarily a bad thing, and there’s still not enough evidence to determine whether acceptable online sexual expression if harmful, beneficial or both.

There’s obviously some appeal in a different set of personal boundaries, it’s just defining the groundwork for alternate approaches that’s challenging.

Popularity: 5% [?]

The View from a Wheelchair

Australian Second Life resident, Seshat Czeret, provides her second guest post. Thanks Seshat!

There is always a lot of talk about ‘accessibility’, so-called ‘making things usable for the disabled’. You also hear a lot about phrases like ‘discrimination’, ‘equal opportunity’ and ‘political correctness’. It can be difficult to work out what is actually needed to help a disabled person live a fulfilling and useful life, and what is excessive ‘correctness’. Hearing what life is like for a disabled person can help.

I’m disabled. I use Second Life extensively. This is my story.

In the atomic world, the fleshworld, I’m almost totally housebound. I can only do chores – or SL work – for a short time before I have to rest. I only have a few hours a day in which I’m functional, and even for those I’m not fully functional. I haven’t been since I was a teenager. Some days – even some weeks or months – I have even less, or am not functional at all.

When I do go out, I have to use a mobility scooter or a wheelchair. I can walk, but walking the length of a mall would tire me out to the point where I’d need several hours of sleep to recover. For various reasons – which would probably be boring – even with the assistance of the scooter or the wheelchair, going out is very stressful and leaves me tired. I have to plan outings carefully.

So I can’t do atomic world work. By the time I got to work, I’d be too weak to achieve anything. I’ve tried, over and over again, many times in the last two decades. I’ve done it, but only at the cost of aggravating my problems.

Fortunately for me, I live in the 21st Century. I can do work from home! I’ve done voluntary work for the Open Source community. I’ve done other sorts of online voluntary work. I’ve written articles, and twice written a book. Unfortunately, the pace of work expected of an author of books exceeds what I can do – the first time I wrote a book, I was more than a year recovering.

But in Second Life, I can be useful.

In Second Life, I teach. I only have to be focussed for an hour and a half or so at a time, which is a stretch of time I can manage. And I don’t have to leave my house, exhausting myself, to do so. I can teach in text, with student questions also in text, so my hearing problems don’t matter. Much of the typing is done in advance, so I don’t overstrain my arms and hands, and only have to type the personalisation of the class for the individual students I’m teaching that day.

In Second Life, I am an NCI helper. I sit and listen in on the NCI chat/questions group channel. When there’s a problem I can help with, I can choose to respond – or not! If I’m having a high pain day, I let others catch that question. If I’ve responded to too many questions and need a break, I let others catch that question. If I can answer, however, I will.

In Second Life, I run a business. I don’t have to be there all the time, I can set things up and then go collapse into my bed. I can create things that other people like, in the times when I am functional, and rest when I’m not. I can do the business management stuff when I’m capable of it, not to someone else’s timeframe.

Best of all, in Second Life, my body works. I can run, and dance, and fly, and ‘talk’, and ‘hear’. I can attend art shows, or watch people creating art in sandboxes.

In Second Life, I am a person and not a disability.

Popularity: 5% [?]

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