John Suler's The Psychology of Cyberspace
This created created May 1999; Revised August 2000, Jan 01, March 04 (v2.5)


Psychotherapy in Cyberspace

A Five Dimensional Model of Online and Computer-mediated Psychotherapy


Introduction


1. Synchronous / Asynchronous
2. Text / Sensory
3. Imaginary / Real
4. Automated / Interpersonal
5. Invisible / Present

Creating Group Experiences
A Cybertherapy Theory
The Role of the Professional


An earlier version of this article appeared as: Suler, J.R. (2000). Psychotherapy in cyberspace:
A 5-dimension model of online and computer-mediated psychotherapy. CyberPsychology and Behavior, 3, 151-160.


Relationships in cyberspace has become a new field of study in psychology. Within that topic area, we may include the study of computer-mediated counseling and psychotherapy - i.e., "cybertherapy" involving the Internet, local networks, and stand-alone computers. Some researchers and clinicians define cybertherapy or "e-therapy" as clinical work via e-mail or chat - work that is text-based, usually ongoing, and mostly or exclusively conducted through the Internet. In the model proposed in this article, I am suggesting a more comprehensive perspective: cybertherapy as any psychotherapeutic environment created by computers and designed, facilitated, or prescribed by a mental health professional. The utility of this perspective is its power to outline the various elemental features of computer-mediated communication and experiences, and how those features can be combined to create a psychotherapeutic process.

While in-person therapy may be the treatment of choice in many cases, there are some unique advantages to computer-mediated and online interventions. One obvious and frequently mentioned benefit of online therapy is the opportunity to reach people who are unable to visit psychotherapists due to geographical, physical, or lifestyle limitations. Computer-mediated therapy also may be an important initial step in establishing what could become an ongoing, in-person treatment. Cybertherapy is a stepping stone to face-to-face therapy, as exemplfied in the treatment of a severe social phobia, first via e-mail and then later in-person, when the client's interpersonal anxiety has diminished to a level where such contact can be tolerated. Other advantages, as I'll discuss later, are specific to particular types of online therapy.

Although I won't discuss these issues in depth, some of the important concerns being raised about cybertherapy involve legal and ethical issues (see the ISMHO White Papers).

Some people say that in psychotherapy, it's the relationship that heals. If this is true, then might cyberspace offer different types of therapeutic relationships based on the different types of communication it offers? As compared to in-person therapy, online therapy is unique in how it provides the opportunity to interact with clients via different pathways or channels, each one having its unique pros and cons - each one being a slightly different type of relationship. The boundaries of time, space, and sensory stimulation can be altered. Imaginary environments can be created. Similar to in-person approaches, people can interact in therapeutic groups, but the groups can be constructed in ways that are not possible in the f2f world. Some or all of the features of the curative environment can be automated, which raises interesting issues about the "presence" of the professional in the healing relationship.

In the sections that follow, I'll explore five features of the communication pathway between therapist and client: synchronous/asynchronous, text/sensory, real/imaginary, automated/interpersonal, and invisible/present. Each of these features is not necessarily a dichotomy, but rather a dimension containing subtle gradients and variations. The five dimensions also overlap and interact. Perhaps we should think of them as flexible tools for examining and classifying any modality of communication - chat, e-mail, message boards, video-conferencing, weblogs, wikis, short messaging systems, etc. - as well as in-person encounters, which is one type of communication pathway.


1. Synchronous / Asynchronous

Synchronous

Unlike in-person encounters, cyberspace offers the choice of meeting in or out of "real time." In synchronous communication, the client and therapist are sitting at their computer at the same time, interacting with each other at that moment. Some examples include text chat, multimedia chat, Internet telephoning, audio-video conferencing, instant messaging, short messaging systems (as in cell phone text-messaging), and even e-mail, assuming the couple are online and rapidly exchanging messages in real time. Text chat includes message-by-message conversations in which a button is pressed to transmit the message, as well as the more synchronous chat conversations where everything that both parties type can be seen AS it is being typed, including typos, backspacing, and deletions - which adds to the spontaneity of the experience. Technical factors , especially transmission speeds, will determine just how closely a synchronous meeting approaches the temporal pace of an in-person encounter. In text-only chat, for example, "lag" due to busy networks may slow down the conversation between the client and therapist, so that there are seconds or even minutes between exchanges. The act of typing also slows down the pace, compared to in-person talking. Fast broadband connections allows auditory and video exchanges that simulate the speed of f2f conversations, much like the standard telephone.

Pros: - The ability to schedule sessions defined by a specific, limited period of time. In most cultures, people understand the boundaries implicit in "an appointment."

- A feeling of "presence" created by being with the person in real time (this may serve important self-object functions, according to self psychology).

- Interactions may show more spontaneity, resulting in more revealing, uncensored disclosures by the client.

- Making the effort to be with the person for a specific appointment may be interpreted as a sign of commitment and dedication.

- Pauses in the conversation, coming late to a session, and no-shows are not lost as temporal cues that reveal important psychological meanings.



Cons: - The difficulties and inconvenience in having to schedule a session at a particular time, especially if the client and therapist are in very different time zones

- There is less "zone for reflection" (the time between exchanges to think and compose a reply), with the possible exception of lag and typing time, which offers a small zone for reflection.

- In the mind of the client, "therapy" may be associated specifically with the appointment and isn't perceived as a process outside of that temporal period.



Asynchronous

In asynchronous encounters the therapist and client do not have to be sitting at their computers at the same time. Usually this means there is a stretching of the time frame in which the interaction occurs, or no sense of a time boundary at all. The perception of a temporally locked "meeting" disappears, although sitting down to read (or view) a message may subjectively feel as if one has entered a fluid temporal space with the other person. Typical examples of asynchronous encounters include e-mail, message boards, weblogs, and delayed viewing of audio and audio-video recordings. However, even systems usually conceptualized as synchronous may be used asynchronously, as in people leaving a chat channel open for an extended period of time and periodically checking it to see what others have been saying.

Pros: - There are no scheduling problems or other difficulties associated with a specific appointment time. Different time zones are not an obstacle.

- The convenience of replying when you're ready and able to reply.

- There is an enhanced "zone for reflection" that allows the therapist and client to think and compose a reply. For the client, this might have important implications for issues concerning impulsivity, stimulating an observing ego, and the process of working through. For the therapist, replies can be more carefully planned and countertransference reactions managed more effectively.



Cons: - The professional boundaries of a specific, time-limited "appointment" are lost. Because there aren't yet any standards in our culture about interacting with a professional in an asynchronous time frame, the therapist must create them in a way that makes sense to the client and that works for the therapist. The therapist could be overwhelmed by contact from the client, as in receiving numerous and frequent e-mails.

- There may be a reduced feeling of "presence" because the client and therapist are not together in the moment.

- Some of the spontaneity of interacting "in the moment" is lost, along with what spontaneous actions can reveal about a person.

- There may be some loss of the sense of commitment that "meeting with me right now" can create.

- Pauses in the conversation, coming late to a session, and no-shows are lost as a psychologically significant cues (although pacing and length of replies in asynchronous communication may serve as cues).




2. Text / Sensory

Text

A large majority of the interactions occurring via the Internet are typed text. Lacking sounds and images, text conversations are not rich sensory encounters. Examples are text-only chat, e-mail, message boards, newsgroups, short-messaging services via cell phone, and even web sites - including online journals and weblogs - that people use to express and explore themselves with the help of feedback from others, including, perhaps, a therapist. E-mail is a the method often used by psychotherapists to work with clients, mostly because it is easy to use and a very popular method of communicating. More sensory-rich styles of communicating - as in Internet telephoning and audio-visual conferencing - require extra equipment, more technical know-how, and fast Internet connections in order to work smoothly. Even though I'm distinguishing text from sensory communication, there IS a visual component to typed text conversations - for example, in the creative use of smileys, spacing, punctuation, ASCII art, special keyboard characters, and font size, color, and style. Also, the tools for inserting graphics, audio, and video into e-mail and bulletin board forums are becoming easier to use. For the most part, however, people stick to typed text.

Pros: - It's easy to save permanent records of some or all of the communications (text files are small). Theoretically, a whole online psychotherapy could be preserved, word for word. Saved records give the therapist and client an opportunity to review and evaluate past encounters. They also could be valuable in supervision and research.

- The absence of face-to-face cues encourages some people to be more honest and expressive (the "disinhibition effect").

- Some people, due to cognitive or interpersonal style, may naturally express themselves better through writing, and/or comprehend others better via writing. They may also comprehend others better by reading than by listening.

- Some people who balk at seeing a therapist in-person (due to anxiety about self-disclosure, the stigma of being a "patient," etc.) may be more willing to seek text-based help due to the anonymity it offers.

- The process of writing may tap therapeutic cognitive processes and encourage an observing ego, insight, working through, and (especially in asynchronous text such as weblogs) the therapeutic construction of a personal narrative, as in journal writing and bibliotherapy. For some people, text communication will tap and strengthen cognitive processing, which could be an asset in cognitive therapies.

- The sometimes ambiguous presentation of typed text can draw out transference reactions, which may be useful to the psychoanalytic therapist.



Cons: - Due to writing skills, typing skills, and cognitive/interpersonal style, some people cannot effectively express themselves through typed text or efficiently understand others when reading text.

- The absence of face-to-face cues encourages some people to regress and act out unproductively (the "disinhibition effect").

- Important face-to-face cues such as voice tones, body language, and physical appearance, are lost. In-person, a therapist very quickly may note that a client is sick, drunk, depressed, etc. Online, without the obvious visual and auditory cues, the therapist will have to rely on other, probably much more subtle indicators.

- For some people, the lack of physical presence may reduce the sense of intimacy, trust, and commitment in the therapeutic relationship. Typed text may feel formal, distant, unemotional, and lacking a supportive and empathic tone.

- The sometimes ambiguous presentation of typed text can lead to misunderstandings and exaggerated projections and transference reactions, which could undermine some therapeutic interventions.

- The identity of the person who sent the text messages may be difficult to verify, which raises important confidentiality issues. People not involved in the therapy also could obtain access to saved messages.


Even though chat and e-mail are both typed text, the fact that chat is usually synchronous while e-mail is usually asynchronous makes them very different styles of communicating. As a result, the significance of the pros and cons listed above may vary for each. For example, the therapeutic value of self-reflection, working through, or writing personal narratives may be much more powerful in the slower paced e-mail correspondence than in "on the spot" chat. This is a good example of how the interaction of the 5 dimensions significantly influence the therapeutic aspects of a particular communication pathway.


Sensory

A robust sensory encounter includes sights and sounds. Audio-visual conferencing includes both, telephoning involves only voice, cell phones can transfer pictures via the web. These communication methods attempt to recreate the sights and/or sounds of an in-person encounter. In this category of sensory communication, we may also include the much more imaginary multimedia experiences. For example, in environments such as the SimsOnline, There.com, and Palace, people interact in an imaginative visual scene using sounds, typed text and sometimes voice transmission to communicate, as well as visual icons called "avatars" to represent themselves. These are fantasy-based encounters and not an attempt to mimic the real world. I'll discuss the psychotherapeutic implications of such imaginary encounters in the real/imaginary section. Sensory communication also could include web pages containing graphics - as illustrated by a colleague of mine who interacted for a short period of time with a severe schizoid patient almost exclusively through pictures uploaded to their web sites.

Even though I'm distinguishing text from sensory communication, there IS a visual component to text conversations - for example, in the creative use of smileys, spacing, capital letters, punctuation, and ASCII art. Rich text formatting (rtf) enables changes in text alignment, font type, size, and color - which offers a much wider range for organizing and presenting ideas, as well for optimizing self-expression and conveying emotion. Also, the tools for embedding graphics, audio, and video files into e-mail and bulletin board forums gradually are becoming more available. Clients can write about their experiences, as well as talk about and show those experiences, all integrated into one message package. The integration of writing, talking, reading, listening, and showing can be a powerful way to understand, work through and assimilate psychological problems.

Pros: - Multiple sensory cues provides valuable information for understanding the client, such as visual appearance, body language, and vocal expression. Comparing cues from different sensory pathways can be very revealing (e.g., a contrast between what a person says and his body language).

- For some people, more fully sensory communication will tend to tap emotional processes, which could be an asset in therapies that aim to directly access affective states.

- For some clients, the feeling of the therapist's "presence" may be more powerful when multiple sensory cues are available, which can enhance the impact of the therapist's interventions, the therapist's selfobject functions, the sense of intimacy, and commitment to the therapy.

- Being less ambiguous than typed text, sensory encounters will reduce misunderstandings, projections, and exaggerated transference reactions.

- Some people express themselves better through speaking than writing. Speaking is considerably faster and usually conveys information more quickly.



Cons: - Sophisticated sensory communication, as in audio-video conferencing, requires extra equipment, more technical know-how, and fast Internet connections in order to work smoothly.

- Some clients may be less expressive when confronted with a face-to-face encounter. Complex auditory and visual cues may cause anxiety in some people, and in the case of severe pathology may be overwhelming.

- Being less ambiguous than typed text, sensory encounters reduce the opportunity to draw out revealing projections and transference reactions.

- Sensory encounters via the Internet are more difficult to save to permanent record (as in multimedia chat), or would consume a great deal of storage space (audio-visual files are very large).





3. Imaginary /Real

Imaginary

When the ftf and environmental cues of the "real" world fall away, the opportunity for an imaginary world opens up. Cyberspace is filled with fantasy-based communities, some purely text-driven and some highly visual - such as MOOs and MUDs, the multimedia chat communities such as Palace, and many other chat and forum communities where participants assume imaginary persona and participate in creative activities. Some people prefer the flight of pure imagination that is activated by text-only fantasy encounters. Others like the visual effect of imaginary graphical surroundings and creative avatars. Psychotherapists might use this potential for imaginary interactions in their work, including not only the creation of an imaginary environment for their clients, but also having clients participate in MOOS, MUDS, or other imaginary communities as an experiential adjunct to the therapy. For example, by enabling people to participate vicariously in the creation of the imaginary character "Elmer" and his interpersonal relationships, Postmodern Therapy offers those people the opportunity to experiment with a different life and personality, thereby better understanding their own.

Pros: - Well-know techniques such as role playing, psychodrama, Gestalt Therapy dialogues dream enactment and analysis, exposure therapy, and implosion could thrive in an imaginary cyberspace environment using multimedia tools. Exposure therapy using VR technology is already well underway.

- A client's lifestyle experimentation in an imaginary online community may provide very valuable material to be discussed in psychotherapy.

- New styles of therapy can evolve out of imaginary cyberspace tools - for example, "avatar therapy" in which assumed identities become a central feature of exploring the client's sense of self.


Cons: - An excessive focus on imaginary scenarios and identities can become a form of defense and acting out, a diversion from true psychotherapeutic work.

- Some types of psychopathology will not respond well to imaginary scenarios, or may be exacerbated by it (e.g., psychotic conditions).

- Sophisticated technology and fast transmission speeds will be needed for multimedia environments to mature. Will the imaginary "holodeck" experiences of Star Trek ever be possible?.


Real

A Star Trek holographic experience that recreates all of the sounds, sights, smells, and physical sensations of "being there" in the real world would be the most powerful simulation of an actual face-to-face meeting. But we're not likely to see this any time soon. In the meanwhile, audio-visual conferencing is the best Internet technology has to offer psychotherapists who want to meet clients in an encounter that approximates an in-person meeting, where both therapist and client sit squarely in their actual physical and psychological identities. Telephoning, which offers only auditory contact, weighs in at second place in the attempt to recreate "being there" - and probably has only a few advantages over the conventional telephone. The most powerful multimedia environments probably will not be those that attempt to recreate in-person encounters, but rather those that generate new ways to communicate by altering the boundaries of time, space, appearance, and group interaction.

The "real" feature of online communications overlaps with the "sensory" feature, but is not identical to it. The realistic simulation of a ftf session using video conferencing contains sights and sounds. It is a robust sensory experience. However, other sensory-rich online therapies that utilize multimedia technology may be highly imaginative environments. Also, text communication in which client and therapist are "themselves" has a greater reality basis as compared to situations in which one or both may be role playing or somehow altering their identities. Nevertheless, the "real" aspects of the relationship will be greatly enhanced by true-to-life audio and video features.

Pros: - The therapist can more accurately verify the identity of the client.

- For some clients, the feeling of the therapist's "presence" may be more powerful when the therapist appears as a "real" person, which can enhance the impact of the therapist's interventions, the therapist's selfobject functions, the sense of intimacy, and commitment to the therapy.

- Interacting with the "real" presence of the therapist may reduce misunderstandings, projections, and exaggerated transference reactions.

- Some people will feel more comfortable as "themselves" and can express themselves more effectively using their own voice and body language cues.



Cons: - Communication using audio and/or visual technology requires extra equipment, more technical know-how, and fast Internet connections in order to work smoothly.

- Some clients may be more anxious and less expressive when dealing with a realistic face-to-face encounter.

- If saved to permanent record, auditory/visual encounters require much more space.

- Some clients may expect that a computer-simulated in-person encounter will be just like an in-person encounter, which may lead to disappointment (the "close but no cigar" effect).




4. Automated / Interpersonal

Automated

The basic purpose of the computer is to automate tasks for us humans - tasks that we can't do, don't want to do, or would take much longer to do. We can put this function to work in psychotherapy, ranging from simple to very complex activities. Programs already exist that scan e-mail or other text messages in order to detect, tabulate, and rate a person's mood and offensive language. Almost any pattern in language use could be detected and quantified. In between sessions or when the therapist is on vacation, an e-mail program can be set to reply to the client's e-mail. Programs designed to guide clients to self-insight or behavioral and cognitive changes can be used as adjuncts to psychotherapy or as primary components of a self-help program (see, for example, SelfHelpSystems). Even software that serves more as entertainment than as a psychometrically solid assessment can be a useful springboard for discussion in the psychotherapy session with the clinician.

A very sophisticated program may even conduct counseling by itself or with varying degrees of supervision by a human clinician. Programs like "Eliza" have attempted to simulate a talking-cure psychotherapy, with marginal success. But the field of Artificial Intelligence is evolving rapidly and may be able to closely simulate many aspects of verbal human interaction. Some forms of psychotherapy - especially those containing techniques which can be operationally defined - may be more amenable to automation than others.

Pros: - Computer programs may be efficient, objective, and accurate tools in the assessment, testing, and diagnostic phases of treatment.

- Computer programs may work well in helping people make decisions about entering psychotherapy and what type of psychotherapy.

- Diagnostic and treatment protocols that are very specific and programmatic may be very amenable to automation, resulting in a cost effective treatment.

- Some people may at first be more comfortable and expressive with a non-human therapist.

- Computers don't have feelings and can be programmed to have minimal countertransference reactions, making them potentially much more objective and neutral in their work.

- Computers have (in some respects) a superior memory than humans and may be better at detecting patterns of ideas and issues that surface in the dialogue with a client. They might even be capable of detecting changes in voice and body language, as they definitely are capable of detecting psychophysiological changes, such as heart rate, skin conductance, and blood pressure - biological cues that therapists usually cannot detect.



Cons: - Computer programs don't reason or learn nearly as well as humans, and therefore may be very limited in their ability to adapt to changing or new psychotherapeutic situations.

- Some clients will not feel comfortable or expressive with a non-human relationship. Some say that "it's the relationship that heals" in psychotherapy. Can a relationship be formed with a machine?

- Programs have no feelings or countertransference reactions, which can be valuable tools in assessing and treating clients.

- The complexities and subtleties of some psychotherapies may be impossible to recreate in a computer program.

- Empathy, which is a powerful healing force, probably can't be simulated by a computer program.

- A computer program cannot be more knowledgeable or skilled than the psychotherapists who programmed it, meaning it often will be a "second best" choice.


Interpersonal

Humans need humans. Our interpersonal relationships shape us. Relationships indeed can heal. Completely eliminating the therapist's psyche from psychotherapy will probably be a mistake in many cases. Although computers may be objective and dispassionate in their work - although they may have better memories and be more efficient at detecting some changes in the client's words and behaviors - although some clients may feel more comfortable with a computer - they are far inferior to the human in feeling and reasoning about the human condition. And that's what many forms of psychotherapy are all about - especially healing "selfobject" interventions in which the client relies on the mirroring, idealizing, or twinning presence of a human being.

This doesn't necessarily mean that computer-controlled interactions involve a lack of personal touch, authenticity, and real care. After all, a human must program the machine. The program can be an extension of the therapist's presence, personality, and therapeutic intentions. As an example, let's say a clinician is going away on vacation and will not be seeing her clients for two weeks. Some clients will have a difficult time with that lapse in the therapy, especially those with object constancy problems, as in borderline conditions. The therapist informs her clients that she has set up her e-mail system so that if they want to establish contact, they will receive a pre-written message from her. That message could be personalized for each client, if the therapist so chooses. In fact, the therapist could create a series of different messages for each client that will be sent - either randomly or in a specified order - when the client touches base. Or these messages could be sent to clients automatically, without them initiating the contact. There are many possibilities and levels of complexity in creating these automated reply systems, including the use of audio and video recordings. The more sophisticated the system, the more life-like the virtual presence of the therapist. In fact, the level of sophistication of the therapist's virtual "substitute" or "bot" is an important feature that can be adjusted depending on the needs of the specific client. What all these simulations share is the opportunity to expand the client's access to the therapist's presence beyond the boundary of the therapy session. They widen the interpersonal field.

Non-interpersonal resources - Although they may not exactly qualify as "automated," there are a wide variety of therapeutic online activities and resources that don't necessarily require the client's interacting with either a therapist or other people. While clients could pursue these opportunities as a facet of their work with a clinician or as a component of their participation in an online therapeutic group, they could also seek out these activities and resources on their own, with the clinician initially suggesting or "prescribing" those that might be most appropriate for a person (see eQuest). These resources and activities include:

- web sites with information about mental health topics

- online self-help programs (see Clay Tucker-Ladd's Psychological Self-Help)

- online journals and diaries written by people who are similar to the client

- the opportunity to create one's own personal web site or online journal as a means of therapeutic self-expression and exploration

- audio recordings, documentaries, and movies which are available online
(for example, see Therapeutic Cinema)

- relaxation and meditation programs (for example, see this guided meditation on BeliefNet)


5. Invisible / Present

Invisible

The invisibility of the therapist that computers allow overlaps with the automated/interpersonal dimension. If psychotherapy is automated, then it's possible for human therapists to oversee the machines' work, either continually or periodically. Therapists can adjust the program, if necessary, or even "step in" to intervene themselves. If clients believe they are only talking with a computer, then the therapist is essentially invisible.

Other variations of therapist invisibility might include professionals "listening in" on another therapist's individual or group session - for example, observing an e-mail list, perhaps to supervise or back-up the therapist through private communications, not unlike the "bug-in-the-ear" method used in some training programs. Obviously, the client's being unaware of the fact that an outsider is listening and/or secretly intervening raises an ethical red flag. With informed consent, the invisible professional then does become a bit more "present" for the client. Over time, some clients will forget that there is someone observing, allowing the professional to slip more into invisibility. Other clients may never feel comfortable in what becomes a self-conscious, even "paranoid" environment. With permission, a therapist also may silently observe clients in an online support group or "in vivo" in an online community, when these groups or communities serve as supplements to the individual therapy. For clinicians holding office hours via chat or instant messaging for clients who wish to "check in" briefly, invisibility allows them to interact simultaneously with several clients, without a client being aware of another client's presence. Or the therapist can invisibly look over relevant information or past messages with a client while chatting with that client. Although challenging, this type of behind-the-scenes multitasking can be mastered effectively. Invisibility can also allow a team of professionals to brainstorm and coordinate intervention efforts with a particular client, even though only one clinician - the "primary therapist" - directly interacts with that client.

It's also possible for clients to be invisible in a treatment program. They can listen in on individual or group sessions, either with or without the knowledge of the therapist and other participants, resulting in "vicarious" learning and psychotherapy. Again, ethical concerns are crucial. Other possibilities include the client's unobtrusive observation of online support groups and communities, which also may be a rich resource for vicarious learning, especially when a clinician assists the client in making sense out of those observations.

Pros: - Some clients may be more comfortable and expressive when they believe a human therapist in not present.

- Invisible supervisors could be a valuable technique in the training of psychotherapists.

- Invisibility enables a "behind the scenes" rallying of consultants and supplementary resources, even WHILE the clinician works with the client in real time.

- Some invisible clients may benefit significantly from a vicarious learning experience.

- Being an invisible client can reduce or eliminate the cultural stigma of being a psychotherapy patient.



Cons: - Invisibility of the therapist or client can pose ethical dilemmas.

- The curative effects of a healing human relationship are lost when either the client or therapist is not present.

- The client's or therapist's commitment to the therapy may be greatly reduced when their counterpart is not present.

- The idea of being completely "invisible" could lull a therapist or client into a false sense of security. With enough technical know-how, an outsider can detect others participation in any type of Internet meeting. This raises serious confidentiality issues, as is true for all types of computer-mediated therapy ( it should be noted that with high-tech surveillance equipment - which is easily available - outsiders can listen in on almost any in-person meeting).


Present

Presence and the factors that enhance it are important issues in cyberspace relationships. The pros and cons of the client or therapist being present follow logically from the above discussion of invisibility. Psychotherapies that rely on a healing human relationship - including the development of rapport and trust between client and therapist, or a healing selfobject interaction - will require a present professional. The fascinating aspect of computer-mediated therapy is that the degree of presence can be regulated. In mailing lists and chat, one can mostly or always lurk, or periodically "pop in," or maintain an ongoing active participation. The presence of the client or therapist will be maximized when the communication is synchronous and sensory. Here and now, seeing and hearing the real person - as in audio-visual conferencing - will make that person feel more real, alive, and present for most people (some people claim they feel a more direct connection to other's presence during typed text communication). Although the "interpersonal" and "present" factors overlap considerably, it is possible to have an interpersonal psychotherapy that lacks a present therapist (e.g., a therapist pretending to be an automated psychotherapy program), as well as an automated psychotherapy with a present therapist (e.g., psychotherapy with a computer program in which the client knows that a therapist is silently observing). An interpersonal psychotherapy also can have varying degrees of presence of the therapist, as in the difference between e-mail interventions and the more fully sensory and synchronous video conferencing.

Mobile technology is expanding the range and complexity of presence. Using the text messaging systems of cell phones, clients and clinicians can stay in touch no matter where they are. The client can immediately report on in vivo experiences, and the therapist's presence can extend directly into the client's natural environment. Such in vivo communication may prove to be a very useful adjunct to an otherwise conventional psychotherapy, and may in fact lead to new approaches to "field" interventions (e.g., working in vivo with phobic disorders). The combination of mobile technology with social network systems will also enable clients and therapists to immediately locate in any wireless environment "friends of friends" and people with similar backgrounds and interests.


Creating Group Experiences

Although this article mostly has focused on psychotherapy as a one-on-one encounter, cybertherapy should take advantage of the many opportunities available on the Internet for interacting in groups. "Individual/group" could be a sixth dimension. On first glance, this distinction does not seem different than individual versus group work in f2f psychotherapy. However, by applying and combining features from different communication pathways, all sorts of creative group experiences can be provided for clients.

Using layered interactions a group could function at two different levels using two different channels of communication, with one channel perhaps functioning as a meta-discussion of the other. For example, the group could meet for a synchronous session via text chat or video conferencing. Then, using a saved transcript or recording of this meeting as a reference, the group discusses this session via (asynchronous) e-mail. Essentially, this is a computer-mediated enhancement of the "self-reflective loop" in group psychotherapy, as described by Yalom. The group process becomes layered, with a core, spontaneous, temporal experience and a superimposed meta-discussion. Such layered interactions may be especially useful when the core experience is an imaginary group role play (as in psychodrama) with a reality-oriented meta-discussion.

Other interesting possibilities arise from the use of invisibility. In a nested group people could communicate with each other while also being able to invisibly communicate with one or more people within that group. Although such private messaging could create subgrouping and conflict, it also could be useful in enabling group members, as well as the therapist, to offer hidden coaching and support that ultimately enhances the whole group. In overlapping groups individuals or subgroups within one group can communicate with individuals or subgroups from a sister group, which enables a comparing of experiences across groups. Some online clinicians also use a meta-group that silently observes the interaction of people in a meeting and then offer its feedback to the whole group, or privately to individuals during or after the online meeting.

Features of the five dimensions also may be therapeutically targeted for a particular group experience. For example, consider the possibility of an e-mail group for people with impulse control problems, where that "zone for reflection" intrinsic to asynchronous communication becomes an essential therapeutic feature of the group.

Group strategies may involve environments that are one-to-many, many-to-one, and many-to-many. In a creatively self-expressive web page, a person may therapeutically express himself to a group of people. If the group can provide feedback to the person - as in weblogs or "talk-back" features - those replies could be therapeutically beneficial. Communities of weblogs and social network systems (e.g., friendster.com, orkut.com, etc,) enable people to find and communicate with other people who share similar backgrounds and interests. Innovative clinicians will find ways to assist clients in exploring and optimally benefiting from this possibilites.

One major advantage of the Internet over the f2f world is its ability to bring together people who are experiencing similar problems - people who are geographically distant and/or who experience problems that might be rare. There are thousands of support groups in cyberspace which may serve as valuable adjuncts to clients in individual therapy. Similarly, there are thousands of online communities of all shapes and sizes. A client's lifestyle in one or more of them may be the perfect social microcosm for exploring interpersonal style. Given the nature of the client's problems, the therapist might "prescribe" a particular community or specific behavioral assignments within a community. The online community then becomes a laboratory for self-insight and the development of new interpersonal skills.


A Cybertherapy Theory

Psychotherapists from different perspectives may evaluate these dimensions of cybertherapy quite differently. Those who place more emphasis on specific treatment techniques rather than a curative relationship - as in some behavioral approaches - may find automated interventions very useful. Psychoanalytic and behavioral clinicians who work with fantasy-based material (dream work, flooding, implosion) or invented role plays may be enticed by the imaginary dimension of computer-mediated therapy. Asynchronous text communication may be useful to psychotherapists who emphasize the construction of a personal narrative, as in some psychoanalytic therapies and bibliotherapies. Some psychoanalytic workers also will be intrigued by the heightened transference and countertransference that occurs in text-based interactions.

On the other hand, those therapists - especially humanistic thinkers - who uphold the therapeutic power of a face-to-face, authentic relationship may be skeptical of any type of computer-mediated intervention. They may prefer a fully sensory, present, interpersonal encounter - which computer-mediated communication may never be able to generate. Surely, clinicians who work closely with body cues and body contact (Thought Field therapies, for example) will find cyberspace very limiting, perhaps even useless. From a practical standpoint, however, it's hard to imagine any clinician who wouldn't find the asynchronous dimension of Internet communication (especially e-mail) useful as a way to maintain contact with the client.

There are at least three ways to conceptualize computer-mediated psychotherapy. We can think of computers as handy tools to be incorporated into preexisting approaches, as in traditional f2f therapy where the client and therapist communicate between sessions via e-mail, when the client uses online assessment and experiential software as a supplement to the therapy, or when the client's life in online groups serves as an important therapeutic experience that is discussed with the clinician. A second approach is develop a variety of computer-mediated therapies that each focuses on a specific technology as the primary channel of therapeutic interaction, such as "e-mail therapy" and "chat therapy." Each of these therapies could become an area of specialization.

The third approach, which I'd like to emphasize, is conceptualizing cybertherapy as an overarching framework for understanding the therapeutic elements of different communication modalities. For any particular client, a communication environment is created based on an understanding of how he or she could benefit from the various features of the five dimensions - as well as whether the client could benefit from some type of group activity or from online mental health information and interactive software. These features and resources can be combined and modified in a variety of ways to address the needs of different clients and the changing needs of a particular client. Each of the five dimensions accentuates a particular aspect of the psychotherapeutic experience. Some of these aspects may have been neglected or overlooked in more traditional forms of clinical work. In a sense, computer-mediated communication deconstructs psychotherapy (as it deconstructs relationships in general), not only revealing its elemental qualities, but also offering the opportunity to isolate, control, and combine those qualities. Most notable is the ability to regulate:

- the temporal boundary and pacing of the therapeutic interaction, including the degree of spontaneity and the "zone for reflection"

- how much of the therapeutic encounter can be stored and reviewed

- the visual, auditory, and textual components of the interaction, including the resulting degrees of anonymity, intimacy, disinhibition, and transference, as well as the resulting emphasis on cognitive (text) and emotional (sensory) processes

- the imaginary and fantasy-driven aspects of the therapeutic encounter, including the ability to tap the unconscious dynamics associated with these aspects

- the degree of human presence and invisibility, including the power to automate some or all of the therapeutic interaction

- the client's access to online information and resources

- the development of a therapeutic "virtual" self by creating personal web pages and autobiographical journals
- the flexible ability to create unique types of group experiences


Keeping in mind the pros and cons of different communication channels, the therapeutic question then becomes what types of channels and resources might work best for a particular client with a particular problem. What COMBINATION of channels and resources might work best for a person? What SEQUENCE?

There are numerous ways the various dimensional elements can be combined and sequenced in order to design therapeutic environments that address the needs of clients. People who can benefit from intensive depth psychotherapy (e.g., those who are higher functioning, educated, and artistically-inclined) may fare well in rich imaginary and fantasy-driven scenarios, coordinated with a text-based evaluating and processing of the experience. Trauma that needs to be mastered gradually can begin with text-based explorations, then slowly incorporating actual sensory recreations to assist in the assimilation of the trauma. Some therapies (e.g., EMDR) also may invent imaginary text and/or sensory resources to counteract the trauma. Developing the social skills needed to mastering specific difficult interpersonal situations can progress from imaginary/automated/asynchronous scripted role plays with minimal sensory cues (and perhaps an invisible therapist to evaluate and coach) to more challenging spontaneous role plays that are synchronous, interpersonal, and sensory enriched. In order to grapple with issues about intimacy and interpersonal anxiety, schizoid and socially phobic clients may benefit from a therapy that begins with encounters that are text-based, asynchronous, and perhaps even automated - then moves towards more synchronous, sensory, present, and ultimately in-person encounters.

Integrated cybertherapy packages that combine many features of online environments - a "multimedia cybertherapy" - may be the strategy of choice for some clients. Encouraging clients to work with a variety of modalities and resources, including those they prefer as well as those that seem alien to them, can help pinpoint the strengths and weaknesses in their cognitive and social development. Examining the transition between different channels along with continued work within a non-preferred channel may lead to self-insight and the development of new psychological skills. Effective strategies for integration may be the key to cybertherapy.

My colleague Michael Fenichel often speaks about "fit" in psychotherapy. Traditionally, this refers to the effective match between the client and the style of psychotherapy, and between the personalities of the client and therapist. In cybertherapy we also will need to address the degree of fit between the client and the online environment. Where do we begin the therapeutic work and into which environments do we later move? The first step in answering this question is knowing what environments and resources the clinician can offer. In this article, I've touched on some of the many possibilities:

- f2f meetings
- video conferencing
- phone sessions
- one-on-one text chat
- multimedia and avatar chat
- one-on-one e-mail
- message board group therapy
- e-mail group therapy
- chat group therapy
- online support groups
- therapeutic participation in virtual communities
- online self-help tools
- weblogs
- short messaging systems (text messaging)
- online assessment instruments
- social networking systems
- online experiential programs (computerized counseling, relaxation and meditation programs, etc.)
- informational web sites
- personal web sites, online journals
- audio recordings and films
Obviously, clients should encouraged to pick communication modalities and online resources that feel right to them, although - as I mentioned previously - working in environments outside one's preferred mode, outside one's "comfort zone," can be therapeutic. The clinician will need to suggest some choices. That decision might be based on standard psychological testing and diagnostic techniques. People with particular diagnoses and personality styles may benefit from some environments and not others. What would be the best communication and online resources for a person with OCD, a schizoid personality, a paranoid schizophrenic, or a borderline personality disorder? For example, it's possible that people prone to poor reality testing and severe transference reactions may spin out of emotional control when working in the ambiguous environment of text communication, where there are no visual or auditory cues to help ground one's perceptions. Clinicians will also need to develop assessment tools that pinpoint the client's preferences and potentials for working in the unique environments of online clinical work. A simple questionnaire might consist of bipolar items that assess the degree of agreeing or disagreeing with such items as:
- I feel comfortable with computers.
- I like to write.
- I like to read.
- I type well.
- I like to talk on the phone.
- I like to meet and talk to people f2f.
- I like to have time to think about something before I say it.
- I like to be spontaneous.
- I like participating in groups.
- I like acting in imaginary situations.
- I like watching movies.
- I enjoy interacting with computer programs.
- I tend to be suspicious about what people really mean when they say something.
etc.
What's interesting about using a term like "cybertherapy" is that we're conceptualizing the therapy based on the type of communication pathway between the client and therapist, and the implications of that for technique. That's a bit different than the more traditional way of defining a therapy which is more closely linked to one's theory of psychopathology (the "causes" of the psychological problem). It's even possible that our understanding of how different communication pathways affect the therapeutic process may lead to new frameworks for conceptualizing psychological problems. A client, for example, may be unable to leave an asynchronous, text-based style of interaction - in other words, humorously stated, "He's fixated at an e-mail level of interpersonal relationships." Psychological health may be assessed according to the person's ability to move among as well as integrate the dimensional elements of computer-mediated relationships.

This dimensional model of psychotherapy in cyberspace does not replace traditional models or theories. It can be considered an independent framework, a supplementary perspective. Clinicians may use it as a tool when extending their f2f work into cyberspace. What online channel might work best for psychoanalytic therapy, exposure therapy, or the Gestalt "empty chair" technique? Whether one conceptualizes a schizoid client as deficient in adequate social learning experiences, lacking sufficient object relations, or derailed from self-actualization, what online environment might be helpful to that client? The model also may be used as a framework for integrating ideas from other theories. If a psychodynamic clinician and a cognitive clinician discuss their teen male clients who love online fantasy games, they may discover some significant overlap in their concepts of psychopathology and psychotherapy.

As the technology of cyberspace advances, the methods for computer-mediated psychotherapy will also change. Traditional theories and techniques will be integrated with new ones unique to the ongoing evolution of cyberspace. A critical component of this change will be a careful evaluation - and perhaps reinterpretation - of the ethical issues associated with the practice of psychotherapy. The foremost concern in the clinician's mind should always be the welfare and rights of the client as outlined by the evolution of professional guidelines.


The Role of the Professional

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. The familiar motto of interpersonal therapies - "it's the relationship that heals" - clearly highlights the salience of the clinician. Many forms of online psychotherapy will similarly place the therapist in a strategic position for controlling the treatment process. 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 (see Clay Tucker-Ladd's Psychological Self-Help) - 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 advise when needed, and perhaps assists the client in evaluating and assimilating the experience.

This role of "psychotherapeutic consultant" may alter the relationship between professional and client, perhaps chipping away at the (often transference-determined) image of the clinician as an powerful authority figure or "healer." With everyone having equal access to online information and resources - as well as an equal opportunity to express themselves - some researchers have commented on how there is an equalization of status in cyberspace. This leveling of the playing field will reinforce that image of the mental health professional as a psychotherapeutic consultant. Online clinicians of the future will learn to adjust to this change. They will learn to embrace the fact that clients can be active, knowledgeable participants in their own psychotherapeutic endeavors.

The online clinician faces technical challenges. As we all know, the Internet evolves at a fast pace. New communication tools and environments appear every day, and there is no end in sight. Online therapists - especially those who are invested in a multidimensional model of communication pathways and psychotherapy - will be hard pressed to keep up. To be knowledgeable about all the possibilities, they should not rely strictly on their own efforts. They would be wise to consult with communications and Internet technology experts who know what's available and what lies ahead.

However, rather than simply following along and using the software tools invented by the technology experts, the mental health professional may participate in the process of creating these tools based on the needs dictated by psychotherapy or a particular type of psychotherapy. For example, what might be the features of an ideal e-mail program for online counseling and psychotherapy? Consider these possibilities, starting with the more common features and progressing to those more sophisticated and specialized:

-- automatic grammar and spell-checking
-- immunity to virus infections
-- rich-text formatting that is easy to use and fail-safe
-- efficient archiving of messages and Boolean searching of archives
-- sorting of archived messages based on date, subject, file size, username, and keywords in message body
-- easy to use encryption and identity verification
-- efficient integration with IM, phone, and video communication
-- easy to use multimedia enhancements (images, voice)
-- scripting ability that enables the clinician to automatically
insert prewritten phrases, sentences, explanations, etc.
-- automatic recording and statistical analysis of time spent composing e-mail and the size of e-mail messages
-- integration of e-mail archive with billing and documentation systems
-- built-in text analysis tools for the detection of emotional words, thematic patterns, changes in syntax and grammar within a message
-- text analysis tools that compare words, phrases, themes, and patterns across messages
- color enrichment of text based on GSR arousal

Developing a productive synergy between software engineers and mental health professionals may be a challenge. The mental health professional may not understand the technical aspects or even the basic concepts behind new communication systems, thereby failing to see the effective clinical applications of those systems. The quantitative mindset of engineers may result in their difficulty in understanding and appreciating the "unscientific" clinician's insights into human nature. Any attitudinal and paradigmatic gap between them needs to be bridged, otherwise the future of cybertherapy will become lop-sided and incomplete. In fact, the most effective approach to the model of cybertherapy that I propose would be an interdisciplinary team that helps decide what psychotherapy theory, with which clinician, in what communication modality or collection of modalities, would work best for a particular client.



See also in The Psychotherapy in Cyberspace:

Psychotherapy and Clinical Work in Cyberspace


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