John Suler's The Psychology of Cyberspace
This section created in July 00 (v1.0)

Psychotherapy and Clinical Work
in Cyberspace

Introduction and table of contents

Is it possible to do psychotherapy in cyberspace? That's an important question that I explore in the articles of this section of my online book The Psychology of Cyberspace. Let me begin by telling a joke (and this is one I made up myself): How many psychologists does it take to do computer-mediated psychotherapy?...... None! The computer can do it all by itself!

Now the reason why that joke is (or isn't) funny is important. Maybe, like many jokes, it reveals something we're a bit anxious about. Are computers and the internet taking over our lives? Are human relationships being infiltrated and dehumanized by machines? Will really poor computer-mediated psychotherapy replace the tried and true methods of traditional psychotherapy? We could certainly make those arguments and it's something we should be on the lookout for. On the other hand, computers and the internet do offer many new, enriching forms of human interaction - maybe that includes new and enriching forms of that special kind of human interaction called psychotherapy. On the road to reaching that possibility, we must grapple with some rather complex issues.

First of all, is it ethical to attempt psychotherapy in cyberspace? If the therapist is communicating with the client through typed text (as in e-mail, chat, and message boards), all sorts of valuable information - like physical appearance, body language, and tone of voice - are missing. That easily could pose problems in making an accurate diagnosis and evaluating the treatment, which often rely on f2f behavioral cues. Without f2f cues, the therapist also may not be able to verify the identity of the client. Is the person really who he or she claims to be? Is this particular message really from the client or from someone else pretending to be that client? Confidentiality - an absolutely essential feature of psychotherapy - easily could be violated by this difficulty in validating identity, as well as by the fact that outsiders could listen in on the psychotherapy discussion by intercepting transmissions or gaining access to saved messages. Fortunately, these problems have some viable technical solutions, such as creating secure networks and using encryption and user verification software. Video conferencing, which is an important tool in the TeleHealth movement, also can supply many of those valuable f2f cues that are missing in pure text communication.

Technological solutions don't work as well for the legal and political dilemmas of online clinical work. If a therapist in Kansas is working with a client from Japan in a chat room located on a server in France, where is the therapy taking place? To some onliners, those geographical questions may seem moot because the whole point of the internet is that geographical boundaries disappear. However, the question is not moot for insurance companies and professional regulatory organizations that need to know where the psychotherapy practice is located. To whom the psychotherapist is accountable boils down to a matter of geography. In fact, licenses and certification to conduct psychotherapy almost always are determined by where the clinician practices. Is it legal when a psychologist licensed to practice psychology in New Jersey does online therapy with someone in California, or India? Does the American Psychological Association - the national organization for all professional psychologists - have jurisdiction over the psychologist who works online with that client in India? If the psychologist is making bad mistakes, who will be there to evaluate and correct him?

That last question leads to the issue of training and credentials. Is psychotherapy in cyberspace so different from traditional f2f psychotherapy that it requires special training and certification? From the standpoint of clinical theory and technique, this is an important question. It's possible that clinical work in cyberspace is but an extension or a supplement to the more familiar styles of psychotherapy. Or it's possible that entirely unique theories and techniques will evolve within this new communication medium.

This issue raises one last critical question: What do we mean by "psychotherapy?" Put a bunch of professional psychotherapists together to discuss this matter and you'll be very lucky indeed if they come to any agreement at all, other than a very general definition about psychotherapy being a service in which a professional helps a person with a problem. And that controversy exists even before we mix cyberspace into the debate. Whether we call it "psychotherapy" or not, there have been many ways over the past 100 years to apply psychological principles to helping people. Now, in the new millennium, cyberspace offers even MORE possibilities - many never dreamed of just a few years ago. Because there is easy access to people, information, and activities in cyberspace, some of these clinical possibilities involve an intersection of individual and group psychotherapy, community psychology, and a wide variety of educational and personal growth activities. The articles below explore some of these possibilities. In the future, we may choose not to define these forms of clinical work as "psychotherapy," or we may modify our concepts about what psychotherapy is.

CE Credit is available for some of these articles. For more information visit the Behavioral EDU course catalog or see this page about the PsyBC program.

Primary Readings in The Psychology of Cyberspace

CE Credit is available
for some of these articles
Click here for information
eQuest: A Comprehensive Online Program for Self-study and Personal Growth
eQuest is a comprehensive program of exercises and online activities that assists people in addressing some personal issue that they wish to understand better and perhaps resolve. The eQuest philosophy holds that exploring online resources - and developing an online lifestyle - can enhance personal growth.

The Psychology of Text Relationships
A comprehensive synthesis of my ideas about online text relationships, with a focus on applications to online psychotherapy and clinical work.

Myths and Realities of Online Clinical Work
This article by the ISMHO Clinical Case Study Group explores various misconceptions or "myths" about online counseling, psychotherapy, and other types of clinical work.

Psychotherapy in Cyberspace: A 5-Dimension Model of Online and Computer-mediated Psychotherapy
In this article I propose a "big picture" model of how various forms of psychotherapeutic interventions could be conducted in cyberspace. This overarching "cybertherapy" would be based on the curative features of the different communication pathways that are possible between client and therapist. By combining and sequencing the various features of these pathways, cybertherapy can be designed to match the unique needs of each client. This article is offered for CE credit.

The Future of Online Psychotherapy and Clinical Work
What lies ahead? In this article I look into my crystal ball and see some important issues surfacing, including specialization, interdisciplinary teams, clinical networks, empowering of the client, automated interventions, and a meta-theory of cybertherapy.

The Online Clinical Case Study Group: An E-mail Model
Online peer supervision and case study groups are an effective method for clinicians to share experiences and support each other in their work. This article describes some theoretical and practical ideas about how to set up and manage such a group using an e-mail list. This article is offered for CE credit.

Assessing a Person's Suitability for Online Psychotherapy
These guidelines created by the ISMHO Clinical Case Study Group discuss basic issues to consider in determing whether a person could benefit from online psychotherapy. What communication method should be used to assess the person? How might the person's computer skills, equipment, and online experience affect the therapy? What role might diagnosis, cultural background, and medical issues play ? This article is offered for CE credit.

Conflict in Cyberspace: How to Resolve Conflict Online
This article by Kali Munro explains some of the causes of conflict in cyberspace and offers some excellent practical advice about how to resolve such conflicts.

Maximizing the Well-Being of Online Groups: The Clinical Psychologist in Virtual Communities
My hands-on work in cyberspace has mostly involved creating, facilitating, and consulting to various online groups and communities. I consider this work to be a type of online clinical/community psychology. In this article I describe the types of situations that come up in this work. I also offer my Top Ten List of issues to consider when working with online groups. This article is offered for CE credit.

Report of the ISMHO Online Clinical Case Study Group
One of the groups I created and facilitate, along with my colleague Michael Fenichel, is this case study group of the International Society for Mental Health Online. The group is devoted to in-depth discussions of psychotherapy and clinical cases in which the internet played an important role. This report summarizes the process and outcome for the first year of this group - what we called the "Millennium Group."

Working Hypotheses of the ISMHO Clinical Case Study Group
This document lists the group's hypotheses about psychotherapy and clinical work that involves the internet. Covering a wide range of theoretical ideas and techniques, it serves as the basis for an evolving, practical model to guide our understanding of how and for whom the various forms of online interventions can be applied most effectively.

Avatar Psychotherapy
Avatars are the visual and psychological persona that people use to represent themselves in cyberspace. This article discusses the possibility of an "avatar psychotherapy" in which the client and therapist enact imaginary scenarios with avatars in a virtual environment for the purpose of exploring and altering the various aspects of the client's sense of self.

Computerized Psychotherapy
Can a computer conduct psychotherapy all by itself? In this article I compare the human therapist to the cybershrink, hypothesize about the types of psychotherapy a computer might be able to handle, and describe the results of a project in which my students interacted with the "Eliza" program. The finale is my speculation about the modules that might go into the ultimate computerized psychotherapy program.

The Bad Boys of Cyberspace: Deviant Behavior in Online Multimedia Communities and Strategies for Managing it
The anonymity of cyberspace unleashes all sorts of misbehavior in people, ranging from inappropriate language to pedophilia. This long article explains the cultural and psychological dimensions of online deviance, catalogs the various types of deviant behavior in a multimedia chat community, and discusses the various automated and interpersonal techniques for managing the misbehavior.

Secondary Readings in The Psychology of Cyberspace

To effectively carry out clinical work that involves the internet, a mental health professional also needs to be familiar with some basic issues in the psychology of cyberspace. Below I've selected some articles from this online book that may be especially helpful in rounding out the clinician's background understanding. Clicking on the bullet will produce a pop-up window with a summary of that article.

Cyberspace as a psychological space
The basic psychological features of cyberspace
The black hole of cyberspace
The online disinhibition effect
Identity managment in cyberspace
Personality types in cyberspace
Transference to one's computer and cyberspace
Addiction to computers and cyberspace
Regressive behavior in cyberspace
Integrating online and offline living
In-person versus cyberspace relationships
E-mail communication and relationships
Transference among people online
Cyberspace romances
Therapy and support groups in cyberspace
TextTalk: Communicating with typed text chat
Conflict in Cyberspace: How to resolve conflict online
Extending a Work Group into Cyberspace

Other Resources on the Web

ISMHO White Papers
The web site of the International Society for Mental Health Online contains several useful papers, including John Grohol's series on "Best Practices in E-therapy" (definition and scope of e-therapy, confidentiality and privacy, legal and licensing issues), Craig Childress's Potential Risks and Benefits of Online Psychotherapeutic Interventions, and a research bibliography on online mental health interventions .
This web site also contains a collection of articles about online clinical work, including several by Marlene M. Maheu on telehealth, as well as other pieces on such topics as eHealth, confidentiality in cyberpsychology, providing therapy for cyber-infidelity, and managing professional listservs.

Psychological Applications on the Internet: A Discipline on the Threshold of a New Millennium - by Azy Barak, PhD

Empirical Evaluation of Brief Group Therapy Through an Internet Chat Room - by Azy Barak and Michal Wander-Schwartz

Thoughts about Online Psychotherapy: Ethical and Practical Considerations - by Gary S. Stofle.

Prospects and Limitations of Psychological Testing on the Internet - a comprehensive article by Azy Barak and Nicole English.

Ethical guidelines for doing online clinical work have been proposed by a number of organizations:

Health on the Net Foundation (HON)
American Psychological Association (APA)
International Society for Mental Health Online (ISMHO)

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