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 weil@technostress.com

 

 

FROM THE COUCH TO CYBER-THERAPY

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 jjsmith@abc.edu 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.

Immediacy:

Cyberspace is available 24-hours a day, 7 days a week, 365days a year. With millions of people online, there is always someone who will talk with you, or new information to read.

A World-Wide Community:

You are not restricted to gaining help in your immediate neighborhood or city. The world is at your fingertips with the touch of a button. jjsmith@abc.edu may live 3,000 miles away from you, or around the corner. It matters not. His messages take only seconds to travel either distance.

A Wealth of Resources:

With the touch of a button, John found hundreds of resources for loneliness. There are enough self-help articles and Home Pages on the World Wide Web on how to combat loneliness to fill a dozen magazines.

A Cost-Effective Service:

Many of the resources on the web are free, including all discussion groups and Usenet groups. An online service will charge a monthly fee and an hourly rate (although statistics are not available, it is estimated that the average America Online user spends 30 hours per month online at a cost of about $60) but you can now get e-mail and hook up to the World Wide Web for around $20 for unlimited use.

Anonymity:

You cannot be seen in cyberspace, even when you are in a chat room. Online services and service providers vigorously guard your anonymity. Usernames can be as revealing (drmichelleweil@aol.com) or as covert (cyberdoc@aol.com) as you desire. In effect, cyberspace is the great equalizer.
You only reveal as much as you want which means that stereotypes harbored from visible features can, if you choose, be avoided. You can say anything you want to anyone and the worst that can happen is that they will send you a nasty message which you can choose to take seriously or discard.
So, cyberspace seems to offer an ideal place for information and assistance with personal problems. The Internet is a grand source for providing information and should continue to be mined by all. For example, patients who have questions about a medical condition can make use of online medical dictionaries, Medline, World Wide Web Home Pages, discussion groups and Usenet support groups, just as they might have previously used a library.

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.

Instant Intimacy:

With a communication modality where messages can be passed at lightening speed, over great distances, with seeming anonymity, relationships develop much faster than in real life. All these factors encourage quicker, deeper, more revealing self-disclosure which leads to a feeling that you "know someone" when you really only know the words they have written. And, in many cases, this self-disclosure is "sexualized" more quickly than face-to-face "getting to know you" communication. Anyone who has spent even a few hours communicating online has had the experience of developing relationships that can seem to grow intense over days, rather than months.

Abandonment:

The next time John tries to contact jjsmith he might find that her (his?) e-mail account is no longer active. jjsmith has disappeared from cyberspace leaving no trace, except that John feels like he has lost a good friend.

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:
weil@technostress.com