Here is an article from the National Psychologist's September/October 1996 4th Annual Computer Technology Special Section. It was written by my colleague, Dr. Michelle Weil. If you have comments, please e-mail her at firstname.lastname@example.org
Michelle M. Weil, Ph.D.
Feeling depressed and lonely one evening, John dials up his account on America Online looking for some human contact. First, he checks his e-mail and finds messages from a discussion group on the difficulties in establishing and maintaining relationships, but there are only a few messages and most are on a continuing thread about dealing with children from a previous marriage.
Next, he finds the Usenet discussion groups and locates alt.support.depression (an online support group) and reads the last week's messages. He replies to one from email@example.com about how he (she?) is feeling down and lonely late at night and writes a few paragraphs about how he is feeling the same way. He posts a message to the whole group about how he is feeling and then goes off to another area of America Online while his messages are sent. He considers the chat rooms, but at this time of night they mostly seem to be adolescents and young adults looking to hook up together. Finally he decides to pass the time by cruising the World Wide Web. Pointing the arrow on the screen at a button or two gets him to the web and he asks Yahoo to search for any sites that deal with loneliness. Immediately a list appears on the screen with hundreds of home pages. First, he clicks on Self Help and Psychology Magazine and reads a few short articles by professionals on ways to beat depression. Then, he notices a few sites that seem to be dispensing online psychotherapy -- sites with names like ShrinkLink, Mental Health Cyber-Clinic, and HelpNet. These seem promising so he points and clicks to an online clinic.
After reading a disclaimer warning that cyber-therapy is not a substitute for psychotherapy, John types in his credit card number and pens a 200-word message about how lonely he is feeling. Twenty-four hours later he has a response from a clinical psychologist who sends him a two-page personalized message that includes a list of things that he can try the next time he feels lonely. The psychologist also includes a short note that for an additional fee he and John can connect online in a chat room at a specified time for a "live" session.
Between e-mail discussion groups, online magazines, online support groups, chat rooms, and online psychotherapy, people have a range of opportunities to use cyberspace for therapeutic assistance. Many are modeled after standard support groups and self-help magazines and books, while others explore the new territory of virtual therapy. Take together they offer many benifits.
A World-Wide Community:
A Wealth of Resources:
A Cost-Effective Service:
The Person Behind the Username
Who is jjsmith? Is the person giving advice someone you would call on the telephone, or talk with over coffee? Even if you spend time developing a relationship with someone in cyberspace, your perceptions of them are limited by the information they supply. You cannot see them, "read" their faces, experience their body language, hear their tone of voice. And, as we know, when we don't know something, we fill in the blanks with our own projections---which can be VERY inaccurate.
Problems of Cyber-Therapy
Now, what about Cyber-Therapy? What does it offer for the practitioner and what problems can arise? First and foremost, in a time of shrinking practices and reduced fees, cyber-therapy offers a new niche, a possibility for income in an alternate setting to face-to-face psychotherapy. Second, it increases the therapist's client pool from those within driving distance to anyone in the world with a credit card. Third, it increases your "office hours." Before, you saw patients from morning to evening. Now, you can respond to patient queries at any time of the day or night, including hours before morning sessions, after evening sessions or even during free time slots.
Cyber-Therapy, however, brings with it a host of problems/issues which I view in two arenas -- legal/ethical dilemmas and psychotherapeutic issues. Legally and ethically, there are no current restrictions on cyber-therapy. APA is working on these and they will most likely release guidelines soon. The important topics to discuss include: confidentiality (how do we ensure communications stay private), licensure (if you are licensed in California can you provide cyber- therapy to a patient in Maryland?), record keeping (is a transcript of the interchange sufficient?), fee setting, consumer relations (therapist credentials, area of expertise, ethical advertising, etc.), treatment planning (history-taking, diagnosis, etc.), informed consent and more.
The psychotherapeutic issues are equally important. With written communication through cyberspace the therapist lacks many of the cues upon which psychotherapeutic training and judgment is based. Since therapists cannot see the patients, they lack body language, facial expression or speech style cues. In addition, visual cues are limited, including body type, clothing style and so forth. The absence of these important details makes cyber-therapy ripe for projection on both sides of the relationship. Add to that the previously mentioned issues of instant intimacy, abandonment and immediate access and you have created a new playing field. It is not psychotherapy, I believe, but something quite different. We must not forget this.
Eventually, video-conferencing may remove some of these barriers. However, having done extensive video-conferencing, it is clear to me that even with the top-of-the-line equipment, images coming through a camera do not create the same "feel" of sitting in a room together. In fact, video-conferencing brings to the table its own unique features to address and resolve. Once video-conferencing capabilities are built in to all computers, these issues will need to be explored.
Cyberspace is a new frontier and similarly, cyber-therapists are trailblazers. There is much to explore and many hidden dangers. We need to stay alert, question and continually communicate. In fact, along those lines, there are online discussion groups grappling with these very issues. Contact me if you are interested in hearing more.
So, can true psychotherapy ever make the jump from the couch to cyberspace? I think not. The medium is too different. But, with rapid technological growth, combined with extensive outcome research, who is to say that in 5-10 years we won't have conquered these limitations and be capable of providing a powerful virtual therapy.
If you have comments, please e-mail Dr. Michelle Weil at: