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Myths and Realities of Online Clinical Work
Observations on the phenomena of online behavior, experience and therapeutic relationships.
A 3rd-Year Report from ISMHO's Clinical Case Study Group.
Michael Fenichel PhD,
John Suler PhD,
Azy Barak PhD,
Elizabeth Zelvin CSW,
Gill Jones MA,
Kali Munro MEd,
Vagdevi Meunier PsyD,
Willadene Walker-Schmucker ARNP
Introduction
The phenomena of online experience and therapeutic relationships continue to be a central
focus of the Clinical Case Study Group, sponsored by the International Society for Mental
Health Online.*
Over the past three years, the Case Study Group (CSG) has explored some of the many ways in
which online mental health professionals engage in clinical online practice, either as the
primary treatment modality or in combination with traditional face-to-face (f2f) office
practice. [See, for example, the CSG's Millennium Report (2000)1, and
Assessing Suitability for Online Treatment (2001)2]
As practitioners and clients become more comfortable with, and knowledgeable about, online
relationships and the many available options for synchronous and asynchronous communication,
there has also been a blossoming of "non-traditional" approaches which have, under
the microscope of peer group study, been demonstrated to have remarkable
"therapeutic" potential in ways that have not been widely recognized or understood.
What do most people believe about the possibility of engaging in the type of online work that
we have in fact been doing? We have observed and discussed many new and exciting activities
with great therapeutic potential, among us and between us. The Case Study Group (CSG) has
provided, through peer support and feedback, a laboratory for expanding our understanding of
clinical online phenomena. In detailing some of our experiences we hope to describe how
effective our interventions can be in facilitating positive changes through guided online
mental health activities.
Through this paper, we hope to illuminate the potential for online clinical work, and to share
our evolving understanding of what is truly possible, despite the prevalent myths and
realities which shape our thinking about online "therapy" and the nature of
Internet-facilitated communication and behavior.
Myths of Internet-Based Counseling
Even among mental health professionals who may be otherwise very like-minded about concepts
and principles which guide traditional counseling/psychotherapy approaches, there are some
specific areas of concern which continue to be hotly debated with regard to Internet-
facilitated mental health services. Clearly there does need to be thoughtful consideration
about professional, ethical practice, with particular concern about risk management for
particular types of client situations. Our direct experience among a group of diversely
trained mental health professionals, all with experience offline as well as online, suggests
that there is even more potential than we had imagined for creative and therapeutic uses of
Internet-facilitated communication. Moreover, the entire group acknowledges that what we have
observed through the case presentations, and shared through a peer-supervision model, has
convincingly demonstrated that some things we may not have thought possible clearly are.
At the same time, we have become still more acutely aware of the realities which are well-
known in translating f2f therapies into digital versions, and the complexities involved in
employing sound therapeutic and ethical judgment when situations arise "between
sessions" online.
MYTH #1:
"Online therapy" is impossible, period
"What is therapy? What is therapeutic?" Asking these questions in academic and
clinical settings generally leads to debates about the nature of psychotherapy and counseling
quite apart from the setting in which treatment takes place.
However we define traditional therapy processes and outcomes, the evidence we have seen
regarding therapeutic online relationships suggests that clients have reported self-perception
of increased autonomy, improvement in decision-making and interpersonal relationships, and
more taking of responsibility for self-help and interpersonal engagement. Other benefits
included such additional things as improved online relational skills, within groups and
individual e-mails.
Some contend that regardless of the successes which have in fact been experienced and
reported, the nature of online work carries too many unique risks to justify beginning it at
all. Therefore such work is, or should be, "impossible". Is this a myth, or
reality?
Among the most pervasive misconceptions regarding the Internet not being suitable for clinical
work is the belief that verifying a client's identity or guaranteeing privacy is completely
impossible online. However, that is clearly not the case, given the potential to employ such
tools as secure chat rooms, digital signatures, encrypted e-mail, and other safeguards.
It is important to note that personal computers are relatively easy to break into and obtain
information saved in them, including sensitive reports on clients. On the other hand, however,
this possibility is not greater than breaking into a therapist's office or a locked file
cabinet. Responsible online therapists, aware of problems of breaking into computers and the
easiness of 'copy & paste,' take special measures to secure information, including the use
of access authorization by secret passwords, as well as other advanced technical means.
Informed consent is a basic requirement for mental health researchers and practitioners, both
online and f2f. Online practitioners are careful to provide the public with a means of
evaluating their own qualifications and describe the limits and risks associated with a given
online treatment modality. Some would argue that with such stringent precautions, ranging from
sophisticated technological safeguards to using only personal, password-protected computers,
in fact the online client may enjoy a level of personal privacy which extends beyond what
telephone and even face-to-face treatments in busy office practices can offer.
The issue of establishing identity, positively and absolutely, is one that continues to be
intensely discussed and debated. We have seen examples of online services that, like telephone
hotlines, provide life-saving services to those who might not have reached out at all were
there not a promise of anonymity. At the same time, it is understood that one needs to assess
the risk of a client's misrepresentation of identity in any contracted professional
relationship. For the online therapist, payment is made via means that ensure it's an adult
who is paying, though of course for a session or two (until the adult credit card holder
receives the bill) it is possible for a minor to misrepresent him or herself. Not only the
provider, by the way, is likely to be concerned about who he or she is addressing. It is
extremely important to recognize that the consumer has a legitimate interest in being able to
verify the identity and qualifications of the mental health practitioner.
There are in fact several extant ethical codes -- for example those of the NBCC3 and
ISMHO4 -- that address the need to be cognizant of risks, particularly to the
consumer. From the practitioner's perspective, the rarity of examples where intentional deceit
is used to procure online mental health services by no means outweighs or negates the
potential for providing help to the many adults (or even children and teens, with permission)
who might benefit from remote access to a mental health professional. This is likely to
become an increasingly important area of interest, as the ubiquitous use of computers, cell
phones and PDAs among teens already demonstrates. Their first response in seeking help or
information may now be to turn on the computer. Using the Internet is an easy way to find
help, advice, or peer support, so why not seek a counselor online rather than f2f?
Several unique advantages exist in online work. Many have been described in the literature
already, such as access for the homebound, geographically isolated, or stigmatized client who
will not or cannot access treatment locally. One of our case presentations illustrated vividly
not only the possibility but also the advantage of Internet-based therapeutic support. A pilot
in the military, exploring sexual orientation and afraid of the potential impact of
"coming out" and jeopardizing a military career, demonstrated how seeking help
online was reassuring to the client in terms of confidentiality. The absence of geographic
boundaries allowed the client to select a therapist who appeared to have the expertise and
understanding needed in the client's particular situation.
There are numerous examples of other particular types of clients who benefit from having
access to mental health services via the Internet. Hearing disabled people, celebrities,
business travelers, people who are shy and introverted, concerned about stigma, or socially
phobic, also might find unique advantages to seeking therapeutic activities, self-help
materials, and a diversity of mental health professionals, all easily accessible online.
Online clinical work is not only possible, but offers a unique "elasticity of
communication" that includes several factors, such as flexibility of location and of
time, varying levels of synchronicity, and flexibility to employ various online channels of
contact. Online therapy has shattered three of the basic premises of therapeutic interaction,
which is that it must always, by definition, be based on;
- visible (f2f) contact
- talking
- synchronous ("real time") interaction
Therapies not based on these foundations cannot rely on old conceptions.
Online therapies, experienced as such, not only can be but are being offered and increasingly
accepted and sought after.
MYTH #2:
Online therapy consists almost exclusively of e-mail exchanges
Online clinicians, while they frequently work with e-mail, often use other channels to
communicate with their clients -- instant messaging, chat, phone calls, and in some cases
occasional face-to-face meetings. For some clients, combining different communication
modalities may prove to be a very synergistic strategy. People express themselves differently
when communicating with voice, text, and visuals. Unique aspects of identity and self emerge
in those different modalities. Moving from one modality to another sometimes proves to be a
very important event in the therapy. For these reasons, clinicians may design treatment plans
involving combinations of different channels of communication or transitions between different
channels.
Although text-based communication currently is the most common method for conducting online
psychotherapy, clinicians have begun to experiment with multimedia approaches as well. In
addition to using video to simulate an in-person meeting, clinicians may also utilize virtual
environments in which the client and therapist create visual representations of themselves
("avatars") in order to interact with each other. In the future, this "avatar
psychotherapy" may be very effective in psychotherapies that rely on techniques involving
fantasy, imagination, and role-playing.
Some clinicians already employ multimedia virtual reality, and it is possible that components
of their interventions may be conducted online. Even simply incorporating pictures, graphics,
and video or sound files into the communication between client and therapist can be a very
effective addition to text-based therapy. No doubt, the future of online clinical work will
entail a variety of creative approaches for mixing and matching text, sound, and visuals.
Among the cases which were presented during the 3rd year of ISMHO's Case Study Group
(2001-2002) were some very dramatic and vivid examples of how a therapeutic relationship can
span several modalities and/or "channels" of online experience, such as integrating
the use of synchronous chat sessions with between-session e-mail and/or using a web-based
Message Board to share experiences with others seeking information and support for common
problems and concerns. In some cases, utilizing online bulletin boards as well as e-mail,
clients were also provided with hypertext links (URLs) to access additional sources of
relevant information and support.
There are a number of therapists whose preferred modality is chat, as opposed to e-mail. One
such case, presented to the group, demonstrated the potential for establishing an online
relationship with such poignancy and immediacy that a review of the case session transcripts
was, to our amazement, quite difficult to imagine as having taken place via the Internet
rather than face-to-face (or on the couch).
Among the many useful techniques which were demonstrated and validated through our case
studies, powerful therapeutic relationships were recognized and clarified, replete with
transference and countertransference, deep and immediate emotions expressed by the client, and
the possibility of long-term engagement even with an ambivalent client. We often observed how
this was facilitated by establishing the benefits of true synchronicity through the chat
medium -- especially with good technology and two fast typists -- and then marveled at the
similarity between a text-based transcript and a comparable office session, as well as the
expressiveness and depth of text-based communication.
A chat room is an efficient way to use the therapeutic here & now principle online, with a
limited number of pre-screened participants, led by a well-trained facilitator working
according to pre-established rules.
Internet users whose experience is limited to public, unfacilitated chats tend to think of
chat as superficial, elliptical, and limited in structure, authenticity, and emotional
intensity. It is as if, having seen classrooms used only for drop-in social groups for
teenagers, the observer concluded that serious learning cannot take place in a classroom.
Therapeutic chat is a text-based, synchronous therapeutic encounter facilitated by a skilled
therapist whose interventions are designed to help the client move toward treatment goals.
The more flexible the use of online media, the more different from face to face communication
it becomes, the stronger the case for working online. For example, a hard-of-hearing person
may be more expressive typing text in a chat room than speaking with a hearing therapist or
using a sign language interpreter. A client who travels frequently and whose schedule is
irregular can form a stronger therapeutic relationship with a therapist who can accommodate to
a need for unscheduled sessions and week-to-week changes in availability and time zone.
It is important to note that some client-therapist dyads may in fact decide to embrace a more
"traditional" approach of scheduling a chat session at a given time, and in a few
cases where routine and boundaries may play an important role, this too is an option to use
and integrate into the counseling regimen. One should not necessarily interpret a client's
preference for lack of structure as "resistance" to treatment; rather, seeking
online help may help facilitate the ability to engage in the first place.
In another of our case presentations, a face-to-face weight management group was combined with
online support group and message board and included experts in both mental health and
nutrition, meeting both online and off. This group demonstrated the value of using online work
as a supplement to f2f didactic instruction. Members of this group were invited to use a
secure message board to share information about their backgrounds, stress levels, and any
"emotional" issues that were affecting their eating behavior. Because they also met
f2f each week, the facilitators were able to monitor each member's progress both through their
online participation as well as f2f behavior, to learn more about each person's unique
struggles (often there was not sufficient time for such detailed personal information to be
shared in person), and to provide more customized/personalized attention to each member's
needs. Members reported being able to share more openly with each other online than in f2f
meetings due to feelings of shame, fear of rejection, and avoidance of intimacy or emotional
expression in person (all of which was made easier online). The online components in this
group provided a valuable flexibility as well as familiarity with each member that a f2f group
alone would have lacked.
Message boards (also referred to as "bulletin boards") can be used as a valuable
adjunct to online or f2f therapy. One CSG member had a face-to-face client join the bulletin
board that she moderated on her website. This resource helped the client to make the
transition from discussing her feelings and problems with only her therapist to discussing
them with others (at the board) and later with people in her life. Observing the client in
this medium gave the therapist new and valuable information about how her client interacts
with people. Issues of transference and counter transference arose in this context and were
then addressed in f2f therapy. For example, the client became jealous of the attention her
therapist gave to other members, which led to a deeper exploration of those feelings in f2f
therapy. The therapist experienced counter transference when she felt hurt by a few angry
messages that her client posted about her in the public forum. Because the client's words were
posted online, the therapist was able to copy and paste the post verbatim and send to the
CSG's e-list to receive collegial feedback and support almost immediately before responding.
The Message Board (MB) has been successfully used in a variety of self-help and support
communities, and in other activities ranging from counseling to teaching. One advantage of
using MB's when teaching university courses online has been that they provide a point of
contact for the students and professors which develops in line with the students' use of
"e-mail loops" (group e-mails to which individuals elect to "reply to
all"). Such message boards thread the thoughts of the group together and provide a point
of reference, while students discuss and develop ideas through the e-mail loops. Another
function of the message boards is to house the more permanent thoughts of the group, while
students may discuss and develop such thoughts through use of the loops.
A further use for the message board is seen in such practical applications as providing
college students with a place for class registration, especially useful when the online group
is not housed on a single campus. Message boards can be used for purely informational
purposes as well as to foster social interaction. One CSG member offered students an online
"Chill Out Room" for jokes, fun contact, informal messages, etc. This was
particularly well used as the course ended and students left each other messages of farewell.
One great advantage of a MB, or forum is the very easy use of embedded pictures and links. It
allows members to permanently and easily view all accumulated messages and, very important, to
use an internal search engine.
Members of the Case Study Group used threaded e-mail subject heads in a similar manner, during
vacation times, to maintain the continuity of contact in a non-stress environment between
presentations. The group found this an effective way of maintaining cohesion and contact. In
such ways, health and tele-health professionals are integrating ongoing care and peer support
into our 21st century lives.
MYTH #3:
Text-only is inadequate to convey a richness of human experience
Why do people continue to argue that words alone cannot convey the breadth of human
experience? The whole body of human literature from Homer to hip-hop renders this frequently
stated myth absurd. It is widely believed that Shakespeare saw as deeply into the human heart
as Freud.
In fact, Sigmund Freud himself treated some patients exclusively through written text, from a
distance rather than in person, and he "saw" others on the couch rather than face-
to-face. Freud's psychoanalytic technique was designed to foster the very disinhibition which
naturally occurs so easily on the Internet.
Why, then, is it so hard to believe that a client cannot be emotionally authentic and a
therapist empathic and insightful in text? Our experience as online clinicians, as well as our
personal experience with relationships on the Internet, demonstrates that some individuals are
more honest, more uninhibited, and more expressive in writing than face-to-face. Certain
literary forms, letters and journals in particular, have always been characterized by the
skilled practitioner's ability to be just as authentic, as fully oneself, in text as in
person. Nor does the writer have to be a literary sophisticate. Within the past 50 years,
literally millions of readers have been moved by a candid and artless piece of writing that
was not intended to be read by anyone: the diary of Anne Frank.
Humans are curious creatures. When faced with barriers, they find all sorts of creative ways
to work around those barriers, especially when those barriers involve communication.
Experienced e-mail users have developed a variety of keyboard techniques to overcome some of
the limitations of typed text -- techniques that almost lend a vocal and kinesthetic quality
to the message. They attempt to make e-mail conversations less like postal letters and more
like a face-to-face encounter. Some of these strategies include the use of emoticons,
parenthetical expressions that convey body language or "sub vocal" thoughts and
feelings (sigh), voice accentuation via the use of CAPS and *asterisks*, and trailers.... to
indicate a transition in thought or speech. Use of "smileys" and other commonly
used symbols can convey not only facial expression but also a variety of emotional nuances.
Color and font can be used both for impact and to separate one writer's words from the
other's.
As with all things, practice makes perfect, so people tend to fine-tune and enhance their text
expressiveness over time. As a text relationship develops, the partners also become more
sensitive to the nuances of each other's typed expressions, and together may develop their own
private language and style of communication that contains many rich subtleties not immediately
obvious to an outsider.
While the therapeutic relationship may in some ways be made more complex by the absence of
some sensory cues, in many ways we are in fact learning to work with the presence of new
additional (text-based) data and the power of the word.
Practitioners even among our own small group of clinicians report remarkable responses to many
modes and mediums of self-expression, from synchronous chat to sharing of photographs, poetry,
and autobiographical web pages. All these become "grist for the mill" in the ongoing
therapeutic process. Such activities are easy to share and to facilitate as the home computer
is increasingly integrated into our every day lives. Supplemental materials, which may also
include logs, diaries, works of art, memorials, and self-help/support group communities, may
provide cumulatively more of an all-encompassing therapeutic experience than heretofore
imagined in the non -"text-only" therapy session.
MYTH #4:
Suicide prevention and crisis intervention are impossible online
Assessment of risk and initiation of appropriate suicide intervention is an area which many
mental health professionals do not believe can (or should) be addressed via the Internet. Some
conclude it is impossible to do by virtue of not being able to see a client face-to-face, in
order to take advantage of visual and other cues in assessing the client's state of mind. No
doubt there were similar critics when telephone hot lines were established, which today we
consider a necessary part of the crisis intervention continuum of services especially with
teens, runaways, domestic violence, rape, and other human tragedies. The reality is that
online counseling and support for suicidal people and those in crisis can be very effective. A
groundbreaking program in Israel, for example, has been so successful that many lives have
been saved. It is now impossible to conclude that such work is "impossible".
MYTH: Through Internet-based professional interaction, counselors cannot actually
observe clients; hence their impressions are limited to verbal messages.
Therefore, risk assessment is highly restricted and apparently invalid.
Moreover, because of easy escape and remote communication, online clients in
a dangerous condition, who may need immediate or emergency care, cannot be
followed, detained, hospitalized, or treated.
REALITY: Online counseling and support for suicidal people and those in
crisis can be very effective.
Despite the lack of visibility and consequent nonverbal communication cues,
people in severe emotional distress can effectively be approached and
emotionally touched through synchronous online communication devices. Also,
many people in crisis situations tend to share their experiences and feelings
with anonymous, unseen partners on the Net, as personal inhibitions
diminish. Therefore, a professional crisis intervention service, managed by
specifically trained personnel, can be of much help, as surfers in crisis
and distress are drawn to such virtual places, frequently eager to share
their painful experiences. Moreover, as suicidal notes are being posted in
public online environments -- such as personal websites, blogs, message
boards (forums), and chat rooms -- it becomes easier to identify and approach
individuals in crisis.
There are quite a few websites that pertain to suicide prevention and
include valuable information and self-help resources that might be of help to
people who contemplate suicide. Surfers in distress may use these sites
directly and independent of human
mediation. This exposure to available resources may
be an incentive for seeking further help.
The Internet can be used in conjunction with face-to-face counseling or
telephone hotlines in a number of ways, from referring people to relevant
online readings to providing the opportunity of writing and sharing their
difficulties through emails, to engaging in an online virtual community
constructed and aimed to help people in a similar emotional condition (an
online support group). The Samaritans organization in the United Kingdom, for example,
(http://www.samaritans.co.uk) offers nonstop hotline service for suicidal people,
in conjunction with email service. In the year 2000, over 37,000
emails were received and replied as a part of The Samaritans' emotional
support system.
The Internet can be used specifically to offer support for people
in crisis and those who consider suicide, through direct, synchronous
communication as well as closely watched asynchronous communication devices.
Internet chat and instant messaging (IM) are similar to telephone hotlines in that they enable
direct and immediate communication between people. Unlike the telephone, they provide enhanced
anonymity, opportunity for self-expression through writing, increased ambiguity of counselors,
ease of escape, and enhanced aloneness, thus facilitating depth of self-disclosure and exposure
of personal materials, as well as accelerating the speed of opening up. That is, the
disadvantages of invisibility become advantages, especially in extreme and emergency situations,
where time and depth of confession are essential.
Especially trained counselors or paraprofessional helpers may offer
emotional support online, much as they can do so offline. Nonetheless, the
online environment has the special advantage of integrating several methods
of communication (individual or group, synchronous or asynchronous),
together with effective use of relevant reading materials, as well as
convenient referrals to help resources by hyperlinks or classified list
posted on a website. Unlike the client seen f2f or on a telephone hotline, a person in crisis
or severe emotional distress who contacts an online crisis center may consequently be approached
with an offer of a "tailor-made support suit" that provides a perfect fit, optimally
meeting his/her personal desires, needs, and capabilities.
The use of online support groups is known to have significant impact on people in various types
of distress, including medical diseases, depression, relationship
problems, or other kinds of personal difficulties. As such, online support
groups -- easy to approach, with no threat of identity exposure -- are
efficient means of crisis intervention and prevention of suicide. In combination of these
measures, SAHAR, the Israeli online crisis service
(http://www.sahar.org.il), has proven that suicide can effectively be
prevented and people in crisis and severe distress be helped through entirely
online activity. In its 15 months of operation, SAHAR has provided online
support to thousands of Israelis, and helped in preventing the suicide death
of many of them, sometimes in last-moment detection of people who delivered
farewell notices.
Not only has SAHAR thus proven the value of such a program for the suicidal client with web
access, but also an additional benefit has developed, in that Israelis who reside abroad
contact SAHAR regularly for personal support. Internet-based support is borderless, and
asynchronicity allows convenient interaction from a distance.
MYTH #5:
Effective online counseling for serious disorders is not possible
Aside from concerns about safety, confidentiality, and other aspects that are well-known in
f2f clinical practice, accurately understanding and responding to a client's communication
becomes more problematic when a significant psychopathology emerges during the treatment. In
working with severe personality disorders, for example -- where clients may demonstrate lapses
in impulse control and judgment, and when it becomes difficult to maintain therapeutic
boundaries -- it is sometimes felt that the challenges of managing the course of treatment
online are so overwhelming as to preclude such treatment.
Ongoing clinical experience online reveals many instances in which avoiding the addressing of
serious issues is unnecessary at best, and at worst an ethical failure to act in the client's
best interests. Depressed clients may lack the determination to make and keep a face-to-face
appointment with a clinical professional, yet seize a moment of willingness to reach out by
clicking for online help. Initial assessment may reveal either that the client is completely
unwilling to seek help within his or her community or that none is available. With appropriate
safeguards, such as contracting for a crisis plan and affirming the client's commitment to
seeking local medication evaluation and management, the online therapist may provide essential support.
Addictions, as another example, seldom appear as the initial presenting problem online, but
the experienced addictions professional may pick up cues in the course of ongoing work that
the mental health generalist might miss, such as recurrent mention of heavy drinking or
partying associated with adverse consequences, the client's embarrassment about something he
or she said, or a regretted sexual encounter. It then becomes the therapist's obligation to
reflect these connections over time and, perhaps without actual confrontation, provide some
substance abuse education, until the client becomes ready to acknowledge and address the
problem.
There were several occasions during our case presentations when it was suspected that further
(f2f) assessment might be beneficial, or that motivation to change and persevere through
emotionally demanding situations was inadequate to justify continuing treatment online. Once
again, however, with patience and consistency, along with limit-setting and some strategies
offered by the peer supervision group, it was demonstrated to our satisfaction that some types
of clients, who might well be difficult to treat f2f, in fact did respond well to online work,
demonstrating some increased insight into self-defeating behaviors and using the
"disinhibition" of online work to share painful and intimate experiences which might
not have been possible to address so immediately or quickly in traditional office practice.
An advantage of online work with severely disturbed clients is that clients can choose to use
emails, chat scripts, and other online exchanges (that can be saved) to rehearse, review, and
reinforce therapeutic messages in a way that can be grounding, affirming, and increase reality
testing. Also, the therapist's empathic words can function as a transitional object that can
be internalized over time at the client's pace. Additionally, having access to an
International group of online colleagues has proven very useful in making rapid, appropriate
referrals, sometimes in single-session correspondence or very short-term consultation.
MYTH #6:
Geography doesn't matter when providing mental health services online
To be sure, there are practical considerations which impact on a counselor's ability or
willingness to provide synchronous communication across time zones. In some geographic
locations, notably the United States, there may be legal restrictions on mental health
treatment offered by licensed professionals whose license is limited to practice in the
therapist's particular state. Some states have a regulatory policy which suggests that
cyberspace is not a geographic location and insists that counselors will be construed to be
practicing professionally in the state where the services are received. For the licensed U.S.
practitioner who is worried about the risk entailed, whether tangible or not, or for whom
insurance will not cover Internet-based interventions or liability outside the state,
geography may be a clear and real factor to consider.
While some practitioners may be deterred from crossing state lines for legal reasons, others
may be reluctant to engage clients from other regions due to the concern about lack of
adequate experience within a given culture, or where there is a language barrier. It must be
acknowledged that geography is a relevant consideration in such endeavors as providing
professional therapy services, and this consideration is part of most ethical guidelines for
mental health professionals, which require that clinicians practice only within their bounds
of competency and experience. Working with someone from a completely different culture, time
zone, and social system can clearly be problematic, and this is something to consider before
concluding that "anyone can practice world wide" in any circumstance.
On the other hand, long-distance, cross-cultural training and practice are being conducted and
some very exciting opportunities are emerging due to our ability to shift time and still be
able to focus effectively and respond to another person as if in a shared "here and
now". The Internet clearly presents entire major new opportunities that are proving to
have great potential in ways never before thought possible.
Asynchronous e-mailing is a rich, culturally diverse, time-unlimited method of communication.
It allows all its participants to contribute in their own time (the previous text is there for
reference) and from their own cultural- geographical- time-zone perspective.
While there are obvious barriers to communication in synchronous "real-time" between
two people in discrepant time zones, it was our experience that with some effort and
acclimation, one can effectively use asynchronous communication to participate in ongoing
discussion in a meaningful way. Where a method of shared experience can be maintained, there
are distinct benefits not only with clients but also in participating meaningfully in
"asynchronously live" professional and educational dialogues across time and space.
The issue of time-zone differences was made quite real to CSG members personally, as
participants included mental health professionals from 4 countries, in 5 time zones. Often
those 3 or more hours away from the majority (located in the US) were either experienced as
being delayed in response by several hours, or leading a topic far in advance, while others
were asleep or at work away from the computer, and vice versa. Here is the experience of a
group member in the U.K.:
Working in a different time zone requires its own skills. At first I felt I was left
out of discussions because they all seemed to be happening at a time when I wasn't
online - most of the discussions were taking place between 1:00 and 5.00 a.m. UK time.
However, I re-read the notes about contributing to discussion threads and decided that
my own contributions (whether they repeated what had already been said or not) were of
value to the group since they could confirm what was being said, and also offered a
culturally and geographically different perspective. Once it was my turn to present a
case, the time zone issue changed completely as I found I was generating the
discussion threads and therefore at the head of the trail rather than the back.
In this case, once the participants acclimated to the characteristics of the time-based
realities, communication across time and geographic distance became less of an obstacle, and
more of an enriching experience for the entire group. The implication for such larger
endeavors as improving communication and understanding between peoples of different cultures
and nationalities is profound.
MYTH #7:
Online clinical work always involves one counselor or therapist working with individuals and
groups
Traditional models of psychotherapy -- especially individual psychotherapy -- usually place
the clinician at the center of the therapeutic process. The clinician administers a treatment
or plays a crucial role in creating and facilitating a transformative experience. So too in
many cases of online therapy. However, in other cases the professional may serve more like a
consultant who helps a client design and navigate through a therapeutic activity or collection
of activities.
In cyberspace there are a wide variety of mental health resources, including support groups,
informational websites, assessment and psychotherapeutic software, and comprehensive self-help
programs -- not to mention the potentially therapeutic nature of online relationships and
communities as social microcosms. In the role of consultant, the professional might help a
client design a program of readings, activities, and social experiences that addresses his or
her needs. Rather than being the "therapist" who directly controls the
transformative process, the professional instead helps launch the client into this program,
offers advice when needed, and perhaps assists the client in evaluating and assimilating the
experience.
Group work is also emerging as a potent online activity for both education and therapeutic
growth. Co-leaders may participate f2f, online, or both, such as in the case presentation of a
face-to-face weight management group that also had an online component. In this case each
therapist was able to provide "group as a whole" interventions as well as individual attention
to each member. Members in turn had the benefit of simultaneously interacting with three
professionals with different but complementary specialties. This experience provided a unique
opportunity to integrate group and individual work, online and off, through the collaboration
of allied health and mental health professionals.
Even a short-term intervention or one-time request for help can involve the sharing of
information between colleagues. In one case presentation, the client was writing -- from
another country -- for "advice" about some serious problems. The recipient of the
call for help was unfamiliar with that country's health care system and was also concerned
about the presenting symptoms. As this client was requesting one-shot advice and gave
permission to consult colleagues, the practitioner was able to provide a brief consultation
(pro bono) which included knowledgeable referral information from a colleague in that country
and also some excellent suggestions which were generated through the almost-synchronous
discussion on the CSG list-serv, day in and day out.
In this case, the client was able to access a multi-disciplinary, multi-national consultation
from the comfort and perceived safety of her home, and was directed to appropriate local
services that she could effectively utilize.
MYTH #8:
Online principles are the same as offline principles
Clearly, "people are people", whether talking f2f, on the telephone, or via the
Internet. Clients seeking help online, however, are faced with a computer monitor rather than
a receptionist, and do not have the benefit of immediately seeing all the diplomas and
licenses on the wall, nor experiencing through their own eyes a therapist's warmth or smile or
sense of humor. Nor can they necessarily experience beforehand a counselor's typing speed or
style, nor anticipate e-mail frequency or response speed. The first task for a potential
client may be to determine if the therapist is able and willing to address their individual
need, but then it is important for the therapist to provide a basis for making a decision
about compatibility, or "fit", and the potential to work together in a therapeutic
alliance. Many people are now turning to clinicians they can find online, with the
expectation of a therapist who is knowledgeable and well experienced with the unique nature of
online work.
As mentioned earlier, online clinical work can entail a variety of creative approaches for
mixing and matching text, sound, and visuals. In fact, such work offers us the opportunity to
examine more carefully the elemental components of face-to-face therapy that often are taken
for granted. It allows us to alter those features. Does the relationship exist in real time or
in an asynchronous frame? If it is asynchronous, what are the effects of varying the delay
between exchanges? Does the relationship or experience involve communication via text, or are
visual images exchanged, or combinations of the two? Does the relationship or experience
involve auditory stimulation? If so, what types? Voice? Other sounds? Does the therapeutic
relationship or experience rely on real identities and real environments, or imaginary ones?
How strong is the presence of the clinician in the therapeutic experience? Might the therapist
in some respects be invisible? Might the client in some respects be invisible?
The online therapist needs to develop not only skills but also sensitivities. Aside from the
well-known challenges and adaptations relating to text-only communication, it must be
recognized that even within the same language (e.g., English) there are differences in meaning
and nuance across countries and cultures. Also consistent with general concern for accurate
communication is accurate understanding of one's client's general circumstances. For example,
the spelling of a name may lead to a false assumption about gender. This actually happened
within the group, leading to a misunderstanding that lasted for months. Again, it becomes
important for online practitioners to be careful in making conclusions about names, idiomatic
expressions, and so forth when working across oceans, cultures, and languages.
As with more traditional f2f therapies, online work calls for a relevant set of principles --
a theory of cybertherapy -- that guides us in understanding when, how, and for whom
these various possibilities are therapeutic. Online clinicians search for principles that will
inform us about what combinations of text, sight, sound, and virtual presence are therapeutic
for which people. We are in the process of developing a theory that helps us analyze the
potentially curative ingredients of different communication environments or communication
pathways and for deciding what environments or pathways are therapeutic for which clients.
Online practitioners need to understand the immediate environment and experience of the
client, at the time they are writing, to have an accurate perception of the "tone"
and circumstances at that time. Therapists need to understand and master some characteristics
of online work. For example:
Working online at your own computer means you will be working in a more isolated setting than
you might face-to-face. Preparation for such work will help you to avoid some of the pitfalls
and dips in confidence you could otherwise experience and will be beneficial for those clients
whom you plan to work with online.
There is no doubt that therapists who use the Net to provide therapy should get specific
training in several aspects, including technology, theory, applications, and ethics. Internet
based mental health services should be seen as a new and emerging form of treatment in which
case each practitioner is ethically bound to seek out and participate in appropriate training
and ongoing supervision in order to develop and maintain their competency.
The online mental health practitioner needs to develop skills that derive from training and
experience in a professional discipline such as psychology, psychiatry, or clinical social
work. The clinician must also learn effective techniques for using text to work synchronously
and asynchronously with individuals and groups. In addition, experience in working with
particular issues, groups, or types of disorders must be readily harnessed in ways which make
the therapist's services most accessible and beneficial to the client.
Keeping in mind the unique nature of online clinical work, it appears that there are now new
opportunities for clients to seek, and increasingly find, someone well acquainted with their
particular area of concern. One can now find online any number of therapists who work in both
cyberspace and f2f practice with particular populations and who can now share their expertise
as specialists with others -- clients, students, and colleagues -- via the Internet. In fact,
whole new possibilities for safe and knowledgeable support and treatment now exist. Some
populations, for example, lesbians and gay men, sexual and ritual abuse survivors, and people
with problems related to sexuality or sex may be more likely to ask for and be able to access
therapy when it is available on the Internet.
These populations can have a number of issues in common that may be more readily addressed
online, at least in the initial stages of therapy. For example, people who are struggling with
issues of isolation, secrecy, disclosure, hyper-vigilance, shame, vulnerability, sexuality,
and intimacy may be more comfortable making contact and engaging with a therapist online. (An
article addressing these themes faced by sexual abuse survivors and lesbians and gay men is
available at: http://www.atlantapsychotherapy.com/articles/struve4.htm)
For individuals whose issues of shame, fear, and secrecy are significant, the anonymity and
privacy of therapy online make it easier and therefore more likely that they will access
therapy. People who are afraid of being judged, or who worry that there is something terribly
wrong with them -- something many lesbians, gay men and survivors feel -- find online therapy
way less threatening. Frequently, clients who need to talk about a problem related to sex feel
uncomfortable meeting in person, but are comfortable discussing the topic with a therapist
online.
Many sexual abuse survivors report that they feel too frightened to see a therapist in person,
at least in the initial stages of their healing. It is much less frightening for many such
people to receive therapy online from the safety of their own home.
If a gay person has a high level of concern about confidentiality, receiving therapy online
may be more confidential than walking into a therapy office where they can bump into
acquaintances they know, or could be identified as gay simply by seeing a therapist who
specializes in working with gay clients.
Many lesbians, gay men, and child sexual and ritual abuse survivors find that there are no
therapists in their area who understand their unique needs, or if there are, they are not
accepting any more clients. For them, particularly those who live in rural areas or small
cities, accessing therapy online may be a lifesaver.
MYTH #9:
Online training and peer supervision are ineffective
Offerings for formalized training are now beginning to appear in university settings across
the globe. For example, training for counselors to work online is enthusiastically offered in
the UK. There are several courses offering training in Internet skills as well as online
counseling skills. Online counseling is also being offered as a module in many face to face
training courses, in the U.K. as well as in the U.S. and elsewhere, while counseling via the
Internet is an increasingly popular research topic for graduate students.
In one online training module, students initially collaborate in supporting each other while
they get used to the variable reliability and performance of Internet and computer technology.
They compile lists of useful websites, along with tips and tricks for dealing with their
computer/ISP/Internet connection, and compare experiences and notes on what works/doesn't work
when troubleshooting. This need to come to terms with an unreliable technology strengthens
the closed group which has formed for the duration of the course. The impact of such group
strength can also extend to the role-plays they engage in and some students comment on the
powerful opportunity they have had for personal growth as a result.
Another interactive training program presented in the Case Study Group incorporates students
working across modalities, creating an online web project and utilizing a variety of online
resources in a guided "quest" of self-exploring a psychosocial topic.
Increasingly, not only in the training of mental health professionals but in higher education
generally, use of forums, "whiteboards", bulletin boards, and so forth is proving to
be a useful and motivational supplement to conventional classroom lectures. As noted above, it
can also improve social cohesion among students, as in the case of the "Chill Out
Room". Another professor has reported equally good results through the similar strategy
of offering students a forum described as "the cafeteria" which has stimulated
positive social interaction.
Such work with students, using online groups and multi-modal resources, only hints at the
great potential of these resources for various populations of clients and colleagues in the
fields of mental health. There is clearly vast potential and immediate need for bringing
online training, education, and supervision opportunities into line, and up to speed. In some
circumstances such as that of rural practitioners, therapists with physical disabilities, and
perhaps therapists who would like to be supervised by a specialist in another country, online
supervision and training may offer the most viable and ideal form of learning for the
therapist in training.
The work of the CSG itself is a testament to the power of peer support and supervision. It
dramatically illustrates the power of such an endeavor to stimulate a steep learning curve and
promote enhancement of technical skills, cross-cultural awareness, and familiarity with the
many new issues that have arisen in ethical and professional practice. Rapid sharing of
references and resources through hyperlinks and instant access to peers has also been of great
value for the members of this group.
In terms of advanced clinical training, the value of online peer group supervision has proven
itself to be tremendous. One long-term client was working with the therapist exclusively via
chat and presented to the Case Study Group over a 2-week period, as the case continued
"live". Another case was presented where there was a very serious call for help via
e-mail, and the group shared online resources, suggestions, support, and personal experience
with various treatment providers local to the client.
It might be noted that during these case presentations, there was almost always one or another
colleague present, online, for consultation or assistance with any urgent situation. This
turned out to be tremendously helpful in a number of cases.
Several effective, rapid, and knowledgeable interventions would not have been possible were it
not for the opportunity to utilize both synchronous and asynchronous communication channels,
to consult with respected peers, around the clock, and in some cases around the planet.
MYTH #10:
Any clinician experienced in ftf work can do online work
Anyone who has been practicing in an office and dreaming of "doing the easy thing"
and working online, will soon find new meaning in the understanding of "the therapeutic
relationship". Even if the therapist is a quick typist and wonderful online technician,
perhaps the client is not. Or conversely, we have seen examples of clients using font color,
emoticons, and abbreviations suggesting more natural ease with the medium than many counselors
who offer services but may be newly appearing online. Aside from one's own skills, and the
client's, in order to have a "transparent", natural relationship, which allows for
communication, understanding and empathy, there must be a good "match" between
client and clinician, and an ability and willingness among each to employ the various online
modalities and channels that are available.
It is clearly a myth, or perhaps a wish, that "doing online therapy" is easy and
uncomplicated. There are definitely some very enjoyable benefits, along with some areas for
concern:
Working online from your own home has numerous advantages:
- You can walk the dog more or less when you need to
- You can wear whatever you are comfortable in
- You can stop and make a cup of coffee when you want to
- You can switch off and do something else if you wish
However, online practice can be even more isolating than working face to face (particularly if
the latter is conducted in a practice setting where you are part of a team). Therefore being
comfortable with certain practical skills is important, if the therapist is to avoid tears of
technological frustration.
Working online requires a love of, and respect for, language and words. It is useless to
embark on text-only therapy if the therapist struggles to find the right word to express him
or herself or relies on the computer's thesaurus when writing a letter. When you work in
text only, words are your only therapeutic tools and must be chosen and used with skill. Time
also has a different meaning online:
the immediacy of the communication system encourages instant response, and even asynchronous
e-mails can fly back and forth in what becomes almost a conversation. It may be important for
the client and/or therapist to take sufficient time to process what is happening before making
another contact. Drawing attention to this requires special tact and diplomacy to avoid
appearing "hostile" or "punitive" to the client. The impact of words used
alone may be more powerful than in f2f communication. The online therapist may need to choose
words that are warmer, more sensitive, more caring than might be necessary face-to-face.
It can be lonely at the computer. The client may trigger the therapist's own feelings about
loneliness and it may sometimes become difficult to retain a professional distance. At these
times, the therapist's confidence in his or her ability to work online will be put to the test
and it will be important to have access to others who can be trusted with these doubts.
Supervision of online work either in a peer group or with a supervisor would seem to be one
way of addressing these issues. If supervision is available online, the therapist can take
advantage of the Internet to seek support and guidance when needed, via e-mail to the
supervisor or group, and not have to wait for a scheduled supervision session.
Some of the skills employed by online practitioners are subtle, while others are quite basic.
Some examples follow:
Required therapist skills for effective online communication
Practical skills
- Fast or touch-typing
- Comfort with Internet modalities and software programs (e.g.,IM, chat, email, downloading the latest browser)
- Curiosity and courage to investigate and alter parts of your computer you might not normally bother with (e.g. adjusting the configuration, adding hardware, etc.).
- Comfort responding swiftly when necessary (or tolerating delays between messages)
- Ability to accumulate, store, and use appropriate web links
- Ability to receive, store, and protect communications from clients
- Knowledge of encryption and other privacy technology
- Expressive writing, facility with both language and other available visual cues
- Training/expertise as mental health professional, with a theoretical base to draw upon
Emotional skills
- Comfort describing own and others' feelings in text
- Comfort in a text-only environment
- Ability to make effective therapeutic interventions using only text
- Awareness of how client perceives therapist online
- Skill at clarifying accuracy of online communication
- Love of being online
- Experience with online relationships (synchronous and non-synchronous)
- Flexibility in approach and conceptualization of therapeutic relationships (e.g., believing it's possible to form therapeutic relationships without visual cues or employing traditional psychodynamic, frameworks, concepts, and techniques)
- Confidence with technology and role as online authority
- Tolerance for computer glitches
- Ability to move between modalities (virtual and f2f) in response to client need and circumstances
- Ability to handle acting-out behavior and intensity of emotion as expressed in client messages (ranging from frustration and anxiety to client projections, anger, boundary and abandonment issues, etc.)
Required client characteristics
- Comfort online
- Ability to contract and maintain a shared working relationship online
- Ability to clarify miscommunications, in both directions
- Motivated
- At least moderately fast typist (or has voice technology)
- Reasonably expressive writer, adequate reading/comprehension skills
- Credit card, willing to use it online
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Research suggests that working online is only suitable for experienced face-to-face
therapists. However, that may well change in the next year or two as using the Internet and
working online becomes more widespread. As Internet usage grows, newly trained therapists
will want to develop an online practice (perhaps with little or no face to face experience)
and will want to concentrate on the skills of working online during their training. It is
therefore very important that attention is paid to best practice for training therapists in
this new medium.
As we move further into new possibilities for online clinical work, training will become not
only more necessary, but also more complex. Clinicians will train to specialize in different
types of text-based, multimedia, and virtual reality interventions. Even relatively
experienced online clinicians cannot rely solely on our own efforts in designing these new
computer-mediated approaches. We need to consult with experts in cognitive psychology,
communications, human factors engineering, and Internet technology. In fact, somewhere in the
not too distant future, the most effective model of a cybertherapy program might involve an
interdisciplinary team that helps decide what psychotherapy theory, with which clinician, in
what communication environment, would work best for a particular client. Might the treatment
for that client involve a package of several types of online interventions and experiences,
with the package designed and conducted by the interdisciplinary team? Members of such
interdisciplinary teams are going to be working with each other via the Internet, e-mail,
message boards, chat, and most likely person-to-person systems. The therapeutic environments
they construct for their clients will be part of that network.
All of these possibilities, many of which already are a becoming reality, mean that a face-to-
face clinician cannot simply step into cyberspace and immediately open a practice-not, at
least, if that clinician expects to be as effective as possible. Newcomers will need to
educate themselves about the complex techniques of online clinical work, as well as about the
culture and resources of the online mental health profession.
* CSG3 was sponsored by ISMHO and co-facilitated by John Suler, PhD, and Michael Fenichel,
PhD. 2001-2002 CSG members include Azy Barak, PhD, Gill Jones, MA, Kali Munro, MEd, Vagdevi Meunier,
PsyD, Lois Shawver, PhD, Willadene Walker-Schmucker ARNP, and Elizabeth Zelvin, CSW.
References
1 The Online Clinical Case Study Group of the International Society for Mental Health Online:
A Report from the Millennium Group, retrieved (2002) from http://ismho.org/casestudy/ccsgmg.htm
2 ISMHO Case Study Group, Assessing a Person's Suitability for Online Therapy,
retrieved (2002) from http://ismho.org/casestudy/ccsgas.htm
3 National Board for Certified Counselors, The Practice of Online Counseling,
retrieved (2002) from http://www.nbcc.org/ethics/webethics.htm
4 International Society for Mental Health Online, Suggested Principles for the Online
Provision of Mental Health Services, http://www.ismho.org/suggestions.html
5 Fenichel, M., The Here and Now of Cyberspace, retrieved online (2002) at
http://www.fenichel.com/herenow.shtml
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