We all know many people — and you very well might be one of them — who are married to their gadgets, whether it’s their smart phone, iPad, laptop or some other tech toy.

All this accessibility and portability, while convenient and entertaining, has its downsides. It’s created unrealistic expectations on the job (respond to email at 9 p.m.? OK, boss!), and can hurt relationships, according to psychologist and coach Dana Gionta, Ph.D.

At her practice, she’s seen how technology can compromise one’s connection with loved ones. For instance, after work, some of her clients head straight to their computers. Instead of spending that time with loved ones, they inadvertently isolate and separate themselves, she said. Similarly, they may be physically present but not mentally or emotionally engaged. While they’re sitting at the dinner table, they still might be glued to their gadgets, everyone’s voices a mere hum in their head while they’re dialed in.

As Gionta said, “one of the greatest gifts you can give to a loved one is your time and presence.” But when we’re attached to technology, we convey the message that our loved ones aren’t important to us, she said.

Gionta offered several suggestions for reeling in your gadget use and making sure that technology doesn’t railroad your relationships or your life. At the core, it’s about creating boundaries and sticking to them.

1. Talk to your family.

If you have a spouse and kids, have an open conversation with them about when it’s appropriate to turn to technology and when it isn’t. Think about your most important rituals and times of the day that you’d like to protect (like dinnertime or breakfast on the weekends) and those that are less important. During these less important lulls, everyone can take 30 minutes for tech time.

However, Gionta underscored that every couple and family is different in what works for them. For instance, some couples prefer more alone time than others, so an hour of work or play at night on their laptops isn’t a big deal. Other couples, however, use the evening as their sacred time. The important thing is to be on the same page and for everyone to feel respected and cared for.

2. Establish structure.

If you have a demanding job or a hobby that requires being plugged in, establish a time every evening that you’ll check your email and do your work. If you have kids, that time might be their bedtime.

Allotting the same time every night lets you accomplish your tasks without distraction, reduces your anxiety and won’t interfere with special moments, Gionta said. This way, you’re fitting in technology when it works best for you — instead of doing everything around technology.

3. Maintain “checks and balances.”

Life is filled with exceptions, Gionta said. So there will be times when you’ll have to take phone calls during dinner or work through the evening. The key, she said, is to check in with your loved ones to see if they feel like you’re present and available.

Also, if you have a busy week or weeks coming up, communicate that to your family, so everyone knows what to expect.

4. Keep gadgets in a designated spot.

Let’s be honest: When your smart phone or iPad is close by, it’s temping to grab it and start surfing. Sometimes out of sight really is out of mind. By setting a specific place for using technology (like an office or den), you’re creating a clear-cut physical boundary, she said.

5. Become more self-aware.

If you’re constantly feeling the need to be productive, Gionta said to ask yourself, “Where is the pressure coming from?” Identify whether the driving force is external, like work, or internal, like your own need to be efficient. Once you’re able to spot the source, you can take action to overcome it.

6. Get to the root of the problem.

Setting boundaries at home around tech use is valuable, but if the source of your stress is your job, you’re just creating a Band-Aid. For instance, depending on your job, your boss may expect you to check email at 10 p.m. and respond immediately. Or there may be an implicit expectation at your office to work 24/7. If that’s a problem for you, consider talking to your employer and setting realistic expectations.

If you’re a small business owner, some of your clients may expect you to be at their beck and call early in the morning or late into the evening, especially if you’re just starting out. Consider the pros and cons of being so accessible and speak up if that doesn’t work for you.

7. Notice when you’re slipping.

How do you know when you’re reverting to old habits? Think of your tech use like self-care, Gionta said. If you’re spending less and less time each week being active or socializing with friends, you know your self-care is slipping. It might be subtle such as skipping your evening walk or talking to a close friend once a week instead of your usual two times.

In other words, watch for sly signs that your tech use is increasing. Maybe you’re bringing your phone to the dinner table, using your laptop longer or your iPad before bed or spending more time socializing on Facebook than with your family.

Remember that how often you use technology and let it blur the lines between work and life is up to you and your family. What matters is that you’re running your gadgets — instead of them running you.

Contributor specialties include but are not limited to neurology, engineering, ergonomics, community outreach and advocacy, and new media.  The book’s authors also include medical and social science academicians and clinicians researching and practicing a wide range of treatment methodologies.  Dr. John M. Grohol of PsychCentral is among them.

Most of the book’s 30 chapters address the uses of new technologies in therapy, both in practitioner-client and in peer-to-peer relationships.  Technology applications include e-mail, texting, and chat; virtual reality environments and gaming; videoconferencing; forums and social networks; websites, blogs, and wikis; and podcasts; along with more established modalities like the telephone and the uses of film and media.

Roughly the last third of the book discusses the uses of technology in training and evaluating therapists and in performing research.  Inherent in this section is the recognition that more research in online therapy and training is needed.  Whereas earlier chapters included best practices in using communication-based technologies with clients, these latter chapters adapt best research and assessment practices, such as sampling and validity concerns, within new technological frameworks.

As in the past, these new applications are seen as supplementing, not replacing, face-to-face therapy.  The anonymity offered by some, like identity-stripped texting used by the Samaritans or avatars used in Second Life’s virtual communities, make the Internet a gateway for people who might not otherwise seek help.  As a tool for self- or assisted therapy and for self-education, the Internet offers a greater sense of equality and “reduce[s] the stigma traditionally attached to mental health concerns.”

The advantages of these technologies include cost and travel savings, as well as basic accessibility to therapy in remote areas lacking clinical facilities.  In one example, people living in Bangladesh use cell phones to access distant medical care; in another, a clinic on a remote island in Scotland uses videoconferencing to help treat a patient with an eating disorder.  Teletherapy options are used to treat patients confined to their homes, whether as a result of physical limitations or of social anxiety disorders.  Within correctional facilities, a telepsychiatry clinic provides continuity of care to inmates experiencing institutional transfers, makes their medical records more portable, and eliminates transportation difficulties associated with using an offsite clinic.

The nature of the technology itself aids interactions.  One example given of the Internet’s disinhibition effect is that of an adolescent who texted her therapist in the middle of a face-to-face session in order to communicate more freely.  The use of online chats in family therapy can help defuse power struggles by making sure each member has a turn in the discussion.  Virtual reality programs like Second Life allow patients to explore different identities and test different behaviors in a safe environment, before integrating their new knowledge into actual life.

Similarly, online simulations may be used to train counselors, helping them grapple with common misconceptions in a “mistakes allowed atmosphere.”  Forums connect students in the field with each other, their supervisors, and their professors, while wikis foster collaboration among researchers.

The book includes numerous case studies and composite transcripts of online sessions.  These examples illustrate the importance of adjusting one’s approach to the different communications modalities.  For example, text methods of therapy omit nonverbal cues such as body language or tone of voice.  Users can overcome this limitation by stating their emotions inside parentheses — e.g., “(worry)” or “(feeling pushy)” — or by using abbreviations and symbols called emoticons for expressing emotions.

The decision about which modality to use is made on a case-by-case basis, taking into account such variables as the disorder being treated, the technology available to participants, their ease and facility with that technology, and security and privacy issues.  Remote modes of therapy or training can be synchronous (as in chat, videoconferencing, or virtual reality sessions, where feedback is immediate) or asynchronous (as in e-mails and forums, where responses are delayed).  The former creates a “being with” experience where participants address issues as they arise, while the latter offers therapists more time to reflect on their responses and allows for more quality control in training.  Individual virtual reality programs and games provide a low-intensity service with minimal supervision, while allowing for monitoring by the therapist.  Patients can work at their own pace in areas that include overcoming phobias and managing depression.

Websites, blogs, wikis, and podcasts can be used by professionals to educate lay audiences and colleagues.  These forms of publishing and broadcasting can convey a broad range of subject matter, including fictional case studies, book reviews such as this one, self-help articles, resources for organization members, and psychological exercises.  Material focused on a therapist’s specialty can increase a client caseload.  Online publishing lets one combine formats, offering embedded audio, video, and hyperlinks to relevant sites.  These technologies also foster interactivity and feedback from readers, listeners, and viewers.

The book gives step-by-step guidance and provides examples to help readers reach their intended audience.  It also tells readers how to distinguish between reputable and disreputable websites, and how to make clients better informed as they conduct their own informal research.  Along with its potential to educate, blogging is used by clients as self-therapy and as ways to find community.  Ethical considerations include the setting of ground rules and boundaries if both client and therapist maintain an online presence, so as to avoid inappropriate dual relationships.

Privacy and security issues associated with online communication are still being integrated into ethical standards.  Furthermore, those standards must now accommodate the Internet’s global reach instead of being just country- or state-specific.  Legal issues include the ownership and control of data, the role of third parties like Internet service providers, and the management of location-based licensing and fee structures in an online environment that transcends location.

The Use of Technology in Mental Health: Applications, Ethics and Practice provides guidance on matters of informed consent, ensuring and protecting the identities of therapists and clients, and guarding against unauthorized access to sensitive data.  Detailed discussions of encryption methods and legal interpretations are beyond its scope.  Readers are pointed to the ethical codes of the American Counseling Association and the British Association for Counselling and Psychotherapy; and to electronic resources like the Online Therapy Institute, The Future of Innovation, and other websites in the areas of training, education, and research.

That said, each chapter in this volume is packed with easily digestible information, practical illustrations, and numerous references.  Non-technical readers will appreciate concise introductions to the different applications and the explanations of their terms.

When the Samaritans, one of the oldest support networks for people in distress, began operations in 1953, its services by telephone generated the same resistance that current innovations now face.  The Use of Technology in Mental Health: Applications, Ethics and Practice addresses that resistance with solid experimental and anecdotal evidence, while evaluating the strengths and limitations of therapy’s more modern tools.  This volume forms an invaluable resource for professionals and students involved in all aspects of mental health care.

The Use of Technology in Mental Health: Applications, Ethics and Practice
Edited by Kate Anthony, Msc, FBACP; Deeanna Merz Nagel, LPC, DCC; and Stephen Goss, PhD, MBACP
Charles C. Thomas Pub Ltd: October 2010
Hardcover, 354 pages
$74.95

When it comes to product websites, and even some vendor sites like Circuit City, you get something less and you get something more. Usually the narratives are less detailed and informative, but you get a numerical rating which gleams respectability and validity. (To read about the truth of these numbers, however, read my concerns about the reliability and validity of online ratings in general.)

When we go to YouTube and see people rated a video 3 out of 5 stars, that tells us something instantly. Whether its reliable or not probably doesn’t matter so much, since a video isn’t likely to change any person’s life one way or another.

But when it comes to rating people on their livelihood, like a doctor (or CEO), should their entire life experiences and career be whittled down to a single number (or a bunch of numbers) that try and capture the wide range of variables in their career and professional lives?

Imagine someone who is an expert in the same field as you comes to your workplace, reviews your personnel file, and after a 30 minute interview, puts up a rating on an employee website about how well they think you do as an employee. Imagine employees rating their bosses, or managers rating their vice-presidents, or vice-presidents rating their CEOs. Or a company’s board of directors rating their CEO.

Yeah, we thought that might jog a few brain cells.

The Problem with Rating People on Their Jobs

The problem with rating individuals on their livelihood is that even if we were to spend hours with that individual, observing them do their daily routine, even for days at a time, we still wouldn’t be in a position to rate that individual on their work. Could you imagine someone boiling your work, your entire career, down to such a review? Very few people could. People have bad days. Heck, some people have bad years. We’re only human, after all.

We expect the law of averages to, well, average out the lows and highs in such online ratings, and that the “truth” will somehow be magically revealed by the sheer quantity of people rating a thing online. And for things, this may or may not be true, because there are literally millions of people who may own or use that thing. But there are not millions, or even thousands of people, who use or interact with a single person in their profession. Even a waitress only interacts with a few dozen people on any given day. Same with a doctor.

The world of Web 2.0 is making such differentiation increasingly difficult, as publishers begin to blur the lines between facts and opinions.

Facts are tangible pieces of information having an objective reality. “The sky is blue” is a fact. An opinion, on the other hand, is one’s view, judgment or appraisal of a thing. Opinions are valuable, certainly, but generally have less meaning without knowing something about the person giving the opinion. For instance, if someone I hold in low regard gives me their opinion, I will likely discount it out of hand. If that same person provides me with a fact, however, there is nothing to discount – they are providing me with a piece of objective reality.

If an individual is seeking health information online, generally they are seeking a fairly balanced understanding of the health issue or mental health condition. This has become increasingly difficult in this day and age, however, because sometimes publishers and websites are blurring the lines between facts and opinions. Sometimes we also confuse facts with opinions, or emphasize one over the other, to the detriment of understanding.

Publishers Can Help or Hurt

A website publisher is in a unique position to help someone understand what is fact and what is opinion. To help their readers make these determinations, a publisher or website must work hard to clearly define where they are presenting factual information and where they are presenting other people’s opinions. Sometimes this isn’t as clear-cut as it might seem. For instance, if you compile a large number of people’s subjective ratings about a product or service, the ratings remain subjective (opinions), not objective (facts).

So even if a website collates a bunch of people’s opinions and gives them numbers, that doesn’t elevate the information presented to “fact.” It is still opinion. And such opinion is no substitute for medical advice, professional advice, or an empirical research study. This is a common but potentially dangerous combination of two basic logical fallacies (appeal to belief and biased sample) – if most people in a population group believe something to be true, it is true. Remember that once most civilized people believed the world was flat.

An Example: Rate My Medication

For example, let’s say a website says that 90% of its members report that Medication X gives them a severe headache. Most people would look at that data and say, “Wow, I should stay away from that medication if I can avoid it!” What isn’t reported in such simple data collection and reporting is whether the sample is representative of the population, or whether the medication actually had anything to do with a person’s likelihood of getting a headache. Headaches are very common in the general population – everyone gets them. Randomized controlled research studies have methods in place to measure whether a symptom is likely caused by a specific medication or not.

Generally people’s website self-reports, however, do not have such careful data collection methods. So if I start taking a medication and then notice an increase in headaches, I’m likely to attribute the symptom directly to the start of the medication. What I didn’t mention (since nobody asked me when I filled out the website’s form) is that I also started two other medications at the same time, and stopped drinking coffee. So while I attributed my headaches to only one of the medications, it could’ve been any of the other things.

But We Have Hundreds of Thousands of Users!

Some people believe that sheer numbers of people overcome faulty data collection methods. Seasoned researchers, on the other hand, know better. If you’re not asking all of the right questions from the onset, the data will only be as good as the questions you do ask. Without the full breadth of necessary questions, a website or publisher has absolutely no idea how good (or bad) their data really is. Without that idea, the data must therefore be considered suspect and possibly junk. If it’s mentioned, it should be mentioned in context – that the data was not collected scientifically and therefore may have little or no validity.

When rating whether someone else is “Hot or Not” on the web, or whether a news story is worth reading or not, the lack of validity and reliability in the data is not that important. These kinds of ratings are for entertainment purposes, not for making serious judgments about one’s life or health.

But what happens when a respectable publisher puts these kinds of ratings on a website (maybe with some appropriate disclaimers), providing people with the opportunity to make just such health or life decisions about their care or treatment?

Without a careful discussion of the issues surrounding the validity and reliability of the data (as we have just done), it is the equivalent of providing harmful medical advice. No website should put themselves and their users in such a position, because while it may be “sexy” to be Web 2.0-compliant, it is potentially harmful to people who are vulnerable. Context, professional discussion and careful consideration (including acknowledgment of these issues) can help provide an important balance to these concerns.

As online communities continue to grow with virtually everyone who is online belonging to at least one such community, communities start competing with one another for the same people. Like to talk about the latest technologies and gadgets? You have dozens of large, thriving online communities to choose from. Suffer from depression and want to find an online support group? Dozens of depression support groups are vying for your attention.

Online Support Communities Are Different

But an online health or mental health support community is qualitatively different than other types of online communities. In a mainstream, non-support community, there are more often than not a large number of replies to a post, video, or news item that are short in length. And while there are some non-support communities that are exceptions to this rule, sites such as Digg, YouTube and Slashdot chase the norm – there are far more quantities of replies than there are quality replies. (Which is not to say there aren’t quality replies, just that you often have to read many – or use their built-in reputation systems – to find them.)

Support communities for health and mental health concerns, however, usually have a distinct purpose and an additional emotional connection amongst its members. They are all grappling with a similar serious issue in their lives, such as cancer, a medical disease, or a mental health issue. These communities usually foster a greater social connectedness amongst their members because of their focused subject matter and the seriousness of the concern. Reputation systems don’t make as much sense in these kinds of communities because users can be emotionally vulnerable – reputation systems are seen as just another judgment of their abilities. Such systems are usually inappropriate for a support community.

What Makes a Quality Support Community?

So what differentiates a vibrant, quality support community from one that may be large, but lacking in real social connections? Let’s look at two hypothetical online support communities based upon real-world sites:

Looking solely at number of users and/or number of posts + replies is not a good indicator of a vibrant, socially-connected community. As we can see in the above example, Community A is very large, but not very deep. Like a shallow pool, such online communities give the appearance of immense size, but offer little in-depth quality to its users. Community A also has a lot of repetition in its posts, because it actually encourages people to ask questions that have already been answered time and time again. Because the same question has been asked and answered dozens, and in some cases, hundreds of times already, the replies to each new posting tend to be short both in quantity of replies given, and in the size of each reply (number of characters).

Some online communities rely on the top numbers (number of users or total posts in the system) to suggest they are a large, vibrant community. Only by digging deeper can a person determine whether the community actually is a robust community that encourages social connections.

Social connections are weaker when people are rewarded for their community contributions via external, versus internal, rewards. An external reward is something like a prize for “best reply” or “most replies,” or a community reputation system. An internal reward is something a person feels inside for helping others out because they feel a social connection of some type to the person asking a question, or providing advice or support or information in their post. External rewards are often (but not exclusively) given to compensate for the lack of social connectedness within a community.

Unintentionally, such external rewards may reinforce a shallow, lower-quality community. If a community reinforces quantity over quality, its users learn how to “game the system” by replying in large numbers to increase their standing (or reputation). Even when such communities make an effort to balance such rewards with rewards for quality replies as well, users learn that the more replies one makes, the more likely any given reply will be seen and considered for a “quality” indicator. With billions of web pages online, it’s also far easier to plagiarize a “reply” from an external source, with little worry of being caught (since most such Q&A online communities don’t have the resources to police the community properly).

A set of clearly defined community ground rules are also important to a strong, cohesive online community. While in many online communities, “anything goes” because there are things like reputation systems that are supposed to take care of troublemakers, an online support community is different. Users of a health community expect a higher level of discourse and emotional support, and don’t want to be judged for their posts or opinions (as reputation systems do). Therefore a set of community guidelines — of acceptable and unacceptable community behavior — helps to resolve this issue. Such guidelines also need to be administered by a fair, impartial team of transparent (e.g., known to the users) community moderators. Quality online support communities have both.

Before you understand what it takes to create a successful startup Internet venture, it’s important to examine some recent trends in the online world. These trends help guide us in what may be a successful enterprise, long before we take the first step down the startup road.

In days of yore, say, oh, 3 years ago, websites were largely creations of either an organization or company, or an individual. There was a fairly well-defined line between these two types of websites, and rarely did they intersect.

This circumstance changed with the intersection of a number of trends and technologies, all centered around people being empowered by their own thoughts and ideas. Marketing and business folks call this “user-generated content.” This is typical business-speak for anything that the company or organization hasn’t created on their own.

Typified by blogs, podcasts, vcasts and such, such forms of creative expression allow people the freedom to say what they want, when they want, on their own terms. With millions of people blogging, however, most go unnoticed except to their own circle of friends and family.

But What if People Online Were Better Interconnected?

Enter “social networking,” the ability for technology to connect people to one another in ways not readily apparent in the past. For instance, say you have a friend who knows someone at a company you’d like to interview. You may not realize that friend’s connection, however, unless you mentioned the person’s specific name to your friend. Social networking allows technology to make these connections for us, without the actual messy social interaction traditionally required to make networking connections.

I’ve seen this question from varying folks over the past year or so as the next obvious evolution in the “tagging” craze — “Why don’t we just tag everything and then everything will be searchable?!”

Great question, because it has implications for how one develops websites in almost any field, but it makes for especially interesting fodder in health and mental health.

Should we just tag everything and call it a Web 2.0 day? Do Web 2.0 concepts, such as combining social networking and tagging together, bring something new and valuable to the technology table?

What is Tagging?

Just to bring you up to speed… “Tagging” is the action of adding a bunch of keywords to a piece of content. Content can be a photo (which rarely has internal keyword information embedded in it), a link (again, rarely has any way of expressing taxonomy or categorization internally), or anything you can think of. Then, when you go to search on that keyword, ostensibly you’ll find the stuff you want in some “better” manner. Better is, of course, a purely subjective term, as you’ll see below.

With the services that have been popularized by this notion — namely Flickr and Del.icio.us — the tagging makes a huge amount of sense. People have been struggling for years on how to identify images and photos because outside of the filename, there’s been little intelligence to indexing systems of photos. (Yes, there is metadata, but the Average Joe doesn’t know how or can’t be bothered to use it consistenly.) Flickr simply allows you to associate pieces of text with photos. One could make a similar argument for Web links (URLs), since outside of the title of the link, it’s hard to add more categorization information to the link without external help (e.g., folders).

One of the keys of tagging services such as these is that owners can add keywords to their images, but so can anybody else. The more people who tag the same keywords on the piece of content, the more “relevant” that piece of content is to a search on the same keyword.

Why Tagging Works for Photos, Videos and Bookmarks

There’s no mystery as why the most popular services online today that actually use tagging in a useful, integrated manner are for photos, videos and Web links. These pieces of content are notoriously difficult to keep track of and organize on our computers, much less on the Web. Web browsers have given lip service to helping people organize their bookmarks or favorites, but nobody has every developed a creative solution that “just works” until Del.icio.us came along. The same is true for Flickr or vimeo.

When the network of people who use these systems are just ordinary folk and relatively small in number, I believe these systems can work fairly well. But, like other Web 2.0 projects, when it comes time to scale, they appear to lose something in the transition. I believe that unless such projects are designed from the ground up to address the concerns I’m about to outline below, they are bound to run into scalability issues from a usability standpoint.

How it Was

Historically, psychotherapists and psychiatrists have acted as the gatekeepers to mental health services. While this role changes marginally from decade to decade, most therapists act as the expert to change in guiding the client to a successful resolution to their problems. No matter the specific psychological orientation of the therapist, whether she be a Freudian or a cognitive-behavioral therapist, the professional nearly always takes the lead in guiding therapy, dispensing information about the specific disorder, and acting as a conduit for additional support services in the community.

Therapist as Expert

These roles are defined by specific boundaries, which are often explicitly elucidated early on in the therapeutic relationship. “Here is how I work. These are my expectations of you as the client, and these are the expectations you can have of me as your therapist. Here is what you do in case of an emergency.” The therapist makes it clear that while she is not a friend or advice-giver to the client, she is acting in the role as an expert in human behavior and experience. This role often translates simplistically to the client, “Doctor knows best.” If the professional says that a psychiatric consultation is necessary in order to evaluate the client for medications, the client goes along with it. If the professional says that he works using cognitive-behavioral techniques in order to help effect change in the client’s life, the client goes along with it. If the therapist suggests that couples counseling is in order, the client goes along with it. Very rarely do clients verbalize disagreement with choices made about their treatment, and for the clients that do, they are sometimes labeled as “resistant” or using some similar psychotherapeutic mumbo-jumbo.

At this point, many professionals will object to this characterization of the traditional psychotherapeutic relationship, claiming, “Oh no, I don’t act like that. I’m a partner with the client in helping them change.” While that may be philosophically many therapists’ orientation, their practice is often reduced to making specific recommendations for behavioral or thought changes in order to effect emotional change. Clients who do not follow the recommendations often spend a great deal of time in therapy, and the therapist is left scratching her head as to why.

Dissemination of Information

Nearly all the information the client wanted to know about their disorder or diagnosis was delivered to them by their mental health professional. “What is depression?” would be answered in session by the “expert” therapist or doctor. Ten years ago, this was the client’s primary, and often only, source of such information. Many therapists refused (and still refuse) to share even the client’s own diagnosis with them, often with the claim, “Well, they wouldn’t understand what that means.” The thought of explaining the assorted complexities of the diagnosis, and the entire diagnostic system used within mental health, was un-thought of.

If the client was prescribed a psychotropic medication by a psychiatrist or their primary care doctor, the client was often left with very little information about the possible side effects or even the insert accompanying the medication. “What should I expect while taking this medication,” was often met with a short reply, and no place for the client to get additional information. For those few clients who felt brave enough to actually ask the question. Most clients are often intimidated by their doctors and defer questions altogether, preferring to take a “wait and see” attitude – “If it doesn’t hurt me, I won’t bother the doctor with all of these silly questions.”