John Suler's The Psychology of Cyberspace
This article dated July 01 (v1.0)

The Online Clinical Case Study Group:

An E-mail Model

A hard copy version of this article is published as:
Suler, J. (2001).CyberPsychology and Behavior, 4, 711-722.



Introduction
Setting Up
The Guidelines and Philosophy Message
Acclimation and Introductions
Discussion of Ethical Issues
Presenting, Responding, Pacing
The Dynamics of Text Discussions
Beyond Text Talk
Clinicians are drawn to peer group supervision to share experiences, improve their psychotherapy skills and knowledge, and support each other in their work. Clinical case study groups also can be an effective medium for training and research. Countless numbers of such groups have formed over the past century of psychotherapy. Now, in the new millennium, cyberspace offers a unique environment to host them. In addition to or rather than meeting in-person, such groups can meet online. Although such meetings can be held in chat rooms and via video-conferencing, they currently are most often conducted using message boards and e-mail groups or "lists." This article will focus on an e-mail model for creating and managing such groups. Many of the concepts here also apply to message boards.

Why meet online? There are a number of advantages, If the lifestyles or geographic locations of the clinicians who wish to meet prevents them from doing so in-person, or if their clinical cases are very specialized, thus making it hard for them to find similarly experienced colleagues, then the internet offers an easy connection. The asynchronous nature of e-mail groups also makes them very convenient for even physically close colleagues whose schedules are incompatible. Last, but not least, an e-mail group can be a fascinating communication environment in its own right - different than in-person meetings, with distinct advantages as well as disadvantages.

Exactly how the group is set up and managed will depend on the preferences of the members and the purpose of the group. Many different formats may be quite effective. Here I will describe some basic issues to consider, as well as mention some specific strategies that have worked well for the Clinical Case Study Group of the International Society for Mental Health Online (ismho.org/ccsg), which I and Michael Fenichel created in 1999 as a training and research group for exploring clinical work that takes place in cyberspace.

First, let's mention the challenges involved in creating and managing any type of online group. A problem with an e-mail list is its potentially amorphous membership and process. Without the visual cues of a face-to-face meeting, you're not sure who is present and listening. If the membership is open, you may not even be sure who and how many belong to the group at any given moment. Traditionally, in many e-mail lists the implicit norm has been that you can subscribe and unsubscribe whenever you want, participate or lurk as you wish, respond to others, ignore them, or digress. This loose structure sometimes results in a group that is fragmented, disorganized, and lacking in group spirit and identity - especially if it's a large, open membership list. Also, the partial anonymity due to missing face-to-face contact sometimes "disinhibits" people, resulting in their saying inappropriate things or acting out. Obviously these are not the appropriate conditions for a peer supervision group.

To counteract these detrimental tendencies, it's a good idea to build in some structure, norms, and expectations that will help the group work smoothly, effectively. A major purpose of this article is to describe how. This structuring process should begin with the very first steps in conceptualizing and setting up the list, even before the group actually begins its discussions.


Setting Up

The first step is to decide on the size of the group as well as how and when people are invited to join. Large groups may result in an overwhelming amount of discussion, low intimacy, and a diffuse group identity. Very small groups can result in sparse discussion, insufficient variety of perspectives, and even social claustrophobia. How members are selected - and possibly replaced if they drop out - depends on the needs of each individual group. Under the best of circumstances, members should be knowledgeable not only in the clinical topic to which the group is devoted, but also in the techniques and culture of e-mail lists. As in all groups, the skills and personalities of its members greatly shape the group experience. To help maximize confidentiality, cohesion, and group identity in the ISMHO case study group, we limited the number of members to approximately 15 and kept the group closed during each round of case presentations.

Equally important, the founders of the group must be clear about it's purpose and philosophy. Exactly what kind of clinical work will be discussed? Will it focus on any particular theories or approaches? What values about psychotherapy and clinical supervision does it uphold? Of course, these questions pertain to any clinical group, online or off. When on the internet, the founders also need to be attentive to their attitudes and philosophy about online communication. What do they see as the pros and cons?

Other issues are more practical. What software should be used to create the list? Many possibilities exist, including e-mail programs operating from a private computer, an organization's system, or a publicly available server (such as the traditional "Listserv" program). Using such services as Yahoogroup.com, it's quite easy to set up and manage a group.

When creating the list, it's important to assess how much people know about using e-mail in general and an e-mail list in particular. Some people may say that they use e-mail "a lot" (since it's fashionable) when in reality they may only be casual users who barely understand the basics. As a result, setting up the list may be a slow, sometimes frustrating process. On the positive side, that process can serve as an opportunity for people to familiarize themselves with e-mail lists before the actual online meeting begins.

It's a good idea to have a facilitator or host - and ideally two or three, depending on the size of the group. At least one of the facilitators should be experienced in the customs and social dynamics of e-mail lists. Another host might take on the responsibility of handling technical issues about running the list. Members will have problems and questions. The facilitators might consider the following tips:
- Select list software that's easy to use - Expect problems in subscribing people to the group. Technical snaffoos and even simple typing errors are common, but usually solved easily.

- Some people have several e-mail addresses. Check to make sure which ones they want subscribed to the list.

- To maximize communication within the group, set the "reply" feature in the list software so that replies go to the whole list, rather than privately to the person who sent the previous message. This will build group cohesion rather than encourage private ("backchannel") communication and subgrouping. Yahoogroups and similar services usually have their software set automatically in the reply-to-group mode.

- Once the list is set up, send a short "Hello/Role Call" message to welcome everyone to the list. Some services like Yahoogroups automate this feature. In that message, ask everyone to reply, indicating that they have received that first "hello" message. In turn, reply to their first message so they know for sure their mail is getting through (most list software distributes mail to everyone on the list, including the sender - which is another verification that one's mail is getting through).

- Don't start any formal discussions until you verify that everyone can send and is receiving mail. You may have to prompt some people several times before they reply to the "role call." It may even be necessary to contact some people via private e-mail, phone, or in-person. If so, you already have advanced indications that such people may not be attending to their e-mail from the list. This is not a good sign and should be corrected early.

The Guidelines and Philosophy Message

Once it is clear everyone is on board, send an introductory message containing some suggestions about how to use the list. Don't assume that everyone understands how to participate in an e-mail group. The message may contain technical tips, guidelines about appropriate and inappropriate behavior, as well as a brief summary of the group's purpose and philosophy. It establishes the ground rules and begins shaping the group's culture. Ideally, it will orient people to the practical aspects of how to use the list, as well as set the stage for promoting focused discussions, personal commitment to the group, and a supportive, professional atmosphere. Concerning practical and technical issues, the G&P message might contain the following items (most of which appeared in the message for the ISMHO group):
Reply-to-Group: Remember that hitting "reply" will send your message to the whole group. So avoid the embarrassing mistake of hitting "reply" on a person's e-mail to the group and thinking that your message is a private communication to that person.

Pacing Styles: Remember that people use e-mail at different paces and that servers on the internet may deliver some mail late. Expect some delays in people responding and messages that arrive out of order.

Be Responsive: Although chronic lurking is accepted in many online groups, it is not appropriate here. Reply to people, especially people presenting a case, even if it's just a simple one-liner or an "I agree." On big lists with lots of traffic, some people get annoyed by such short messages, but it's good for our purposes. When people post to a list and don't get any reply, they tend to be reluctant about posting again. No one likes to be ignored.

Repetition is OK: If you are short on time during a particular case presentation, read the initial message presented for the case and respond to that. Don't worry about possibly repeating feedback that someone else might have offered in a message you didn't get a chance to read. Independent thinking that yields different ideas or external validation is valuable.

Be Concise: Avoid long, scrolling messages. Get to the point clearly, efficiently, while showing thoughtfulness and concern. It will take more effort for you, but the net result for everyone will be a more focused, less overwhelming batch of messages. Mark Twain said "Sorry I wrote such a long letter. I didn't have time to write a short one."

Precise Quoting: Avoid long quotes of previous messages. Quote the specific sections you are responding to.

Announce Absences: Let us know when you're going to be away from your computer. That way we will know why you seem to be "quiet."

Watch for Ambiguity: Because there are no face-to-face cues (voice, body language), it's easy to misread the tone and therefore the meaning of someone's message. So when in doubt, ask for clarification. Remember the motto, "Assume good will."

Professionalism: Be helpful to the presenter, not critical. We will expect respectful, professional behavior on this list. Persistent disrespectful behavior will result in your being removed from the group.

Questions? If you have any questions about how this list works - or other ideas and suggestions - please bring it up for discussion. Other people probably have the same concerns.
Over time, hone this message. It may evolve significantly as the group's norms, culture, and philosophy changes. Periodically sending the message to the group may be a useful reminder that helps keeps the group on course. Encourage members to save the G&P message and/or create a web page for the group that contains this information, as well as other resources for the group.


Acclimation and Introductions

Encouraging the group to discuss the guidelines and philosophy message is a convenient way to help members acclimate to the technical and social environment of the list. Some casual conversation should be encouraged as another way for people to get to know each other and adjust to the e-mail medium. To help educate members who are inexperienced in online groups, offer a reading list of articles that cover a range of topics related to online interpersonal interactions, especially e-mail communication. Discussing these readings can be very beneficial in preparing members for the experience that lies ahead.

Once people seem to have settled in, the facilitator can encourage the members to send in a message that introduces themselves to the group. Usually a paragraph or two is sufficient. The facilitator can suggest some information to include in that message (training, professional affiliation, type of clinical practice, etc), or send in his/her own message as a sample, or simply allow the members to approach the task in their own unique, individual style without any specific guidance. In the faceless, voiceless world of online text talk, it's easy to forget who people are. So encourage members to save these introductions for future reference. Creating a web page containing these introductions would make it easy for members to refresh their memories of their comrades.


Discussion of Ethical Issues

An extremely important issue in clinical case study groups is the confidentiality of the clients being discussed (and of the clinician's personal experiences as well). Even under the best of circumstances, e-mail communication is not completely private. Members should be aware of this fact. Accidentally or intentionally, outsiders could gain access to the group's messages. The group members must take specific precautions to protect the anonymity of their clients. At the beginning of each round of case presentations, the ISMHO Case Study Group discussed the ethical standards of the American Psychological Association regarding the use of confidential information for didactic purposes. There are two basic principles that apply to presentations in any educational or training format:
(a) Do not disclose confidential, personally identifiable information regarding patients, individuals or organizations obtained during the course of one's work, unless the person or organization has consented in writing or unless there is other ethical or legal authorization for doing so.

(b) In professional presentations, disguise confidential information concerning patients, individuals, or organizations so that they are not identifiable to others and so that discussions do not cause harm to people who might identify themselves.
The ISMHO group also created and continues to discuss its own list of queries that encourages members to consider these general ethical issues, as well as issues that are unique to an online peer supervision group. Although all of these queries may not be relevant to every case that is presented, they are always important to consider:
1. Are you protecting the confidentiality of the person or group by disguising and/or deleting information that could directly or indirectly reveal the person's offline or online identity, or the group's identity and location?

2. Does anyone on this list have direct or indirect contact with the person/s you will discuss, and could this jeopardize the person's confidentiality or in anyway harm those person/s?

3. Has the person or group given permission for their case to be discussed?

4. What precautions have you taken to safeguard the security of messages from our case discussion (i.e., how have you restricted access to your computer and these e-mail messages)?

5. Are you requesting explicit permission from the appropriate individual and/or the whole group to use quotes or specific material for your presentation?

6. During your discussions with people outside of this list (professional or otherwise), how will you protect the confidentiality of the list and the cases presented here?

A safe, supportive, and confidential atmosphere is significantly determined by the group's membership and structure. To help create such an environment, the ISMHO Case Study Group was limited to approximately 15 members and kept closed during each round of case presentations.


Presenting, Responding, Pacing

Facilitating the group is a delicate balance between providing structure and encouraging spontaneity. Exactly how much structure or spontaneity will depend on the group. There are two basic issues. When and how do people present a case? When and how do members respond to the case?

A completely open format might allow members to discuss a case at any time, with no particular structure or limit-setting. This format allows members to get feedback on a case in a timely fashion, when they need that feedback. In small groups this strategy might work well, as long the subject titles of all messages about a particular case stick to that subject title. However, three or more cases being discussed simultaneously could lead to a lack of focus, confusion, and an overload of incoming messages. In larger groups, such an open format probably invites confusion and overload.

A group might have guidelines about a specific format for presenting a case - not unlike editors who establish rules for authors submitting case studies to a journal. If a particular format is important to the group, it might provide a sample case presentation that is sent to the list or uploaded to a web site. However, it's important to remember that composing an e-mail message is not like writing a journal article. A more casual presentation style that resembles in-person conversation creates a more personable atmosphere. It instills a sense of "presence" which will be important in establishing the feeling that a discussion is taking place, rather than separate individuals reading an author's work. Also, encouraging freedom of expression can lead to many different creative styles for presenting a case. The process is as important as the content.

The length of the initial message may vary. One approach is to write a comprehensive account of the case, as in a journal article. This gives each member a detailed picture from the start, though there is a danger in the message being too long. Customarily, e-mail messages are not tomes, so lengthy case presentations may tax people's expectations and patience. An alternative method is to present a shorter case that contains the essentials, then allowing questions from the group to draw out other needed information. This method encourages a dialogue between the presenter and the other group members. Obviously, the presenter's ability to write in a clear and organized manner affects the quality of the presentation. To optimize the caliber of their writing, members might be advised to take advantage of the "asynchronous" quality of e-mail communication. Compose the initial message, set it aside for a few days before sending it to the list, and then return for editing when one can see it with a fresh eye.

The ISMHO Case Study Group operated with a specific structure for when people presented a case, but with few rules about how. According to a schedule created ahead of time, all members took turns. On a Monday the presenter sent the first message that summarized the case, followed by a two week discussion period. This predetermined schedule gave each presenter ample preparation time, kept the group focused on a case, and helped regulate the flow of messages (in it's first year, a one week discussion period proved to be too fast a pace). Members also were encouraged to bring up in separate discussion threads any issues about "hot cases" that required timely attention. Because no particular rules were set about how to present the initial description of a case, a variety of styles surfaced. Some descriptions were lengthy, some concise. Some written in a formal tone, others more casual. The group is devoted to clinical work that involves the internet, so a few members creatively integrated excerpts from e-mail and chat therapy, or links to posts within the message board communities where the clinician was working.

Once a presenter sends the initial message describing the case, the group - and especially the facilitators - must attend to the pacing of the ensuing discussion. In asynchronous communication people participate at different rates. Some members may be online all day and quick to respond. Others may sign on once every few days. It's important to recognize and adapt to other people's paces. Each group also has its own rhythm, its natural ebb and flow. The facilitators can massage that pattern a bit but shouldn't fight it. It's better to notice, understand, and perhaps discuss the meaning of changes in that rhythm rather than force changes. In the ISMHO group, there typically was a flurry of responses during the first week a case was presented, then tapering off into the second week, with occasional stretches of several days without any messages at all.

Periods of silence may or may not be a problem. Without face-to-face cues, it's hard to tell if people are reading the messages but not replying - or not present at all. A troublesome situation may arise if a member presents a case with few people or no one responding within several days. Especially when feeling vulnerable about discussing their clinical work or opinions, people can project all sorts of meaning into the "blank screen" of messages that don't arrive. The facilitators may make a point of replying when others are not, but sometimes this can become an entrenched pattern where members begin to rely on the facilitators to initiate discussion and/or dislike the facilitator "always having the first word." If people are not completely absent, periods of silence may indicate an incubation period, when members are mulling over the discussion, thinking about how to respond. During the lull that typically occurred during the second week of the ISMHO Group, the facilitators would "hang back" to see what would happen, then perhaps send in a message that summarized their lingering thoughts about the case or the process of the group's discussion.

Several factors contribute to chronic low activity. There may be a tendency for the group to slip into the commonplace attitude on the Internet that lurking or casual participation in an e-mail list is acceptable behavior. Members may become busy in their lives or disinterested in the discussion, though it's difficult to tell the difference between these two possibilities - hence the importance of the guideline about informing the group of one's absences. The preestablished structure and rules of the group can help a great deal in preventing chronic non-participation. The Guidelines and Philosophy Message of the ISMHO group clearly stated that all members were expected to present a case and reply with at least one message to other cases. Perhaps the most difficult issue is what to do about individual people who persistently fail to participate. If the group intends to remove someone from the list, clear rules about when and how this happens should appear in the G&P Message.

The "wheel effect" may pose a problem in some discussions. People respond to the presenter - who is at the hub of the communication pattern - but not to each other. This effect can exhaust the presenter. It also precludes the productivity of group interaction when people bounce ideas off each other, as well as the building of group cohesion when people talk to each other and not to one individual. If the wheel effect emerges, the facilitators may intervene by reacting to people other than the presenter, and by encouraging members to converse amongst themselves.

A more challenging situation occurs when the flow of messages accelerates greatly, resulting in an deluge that overwhelms people. Some will be able to keep up, others will fall behind, resulting in an "in-group" and "out-group" effect. People entering the discussion after a surge of messages may feel reluctant to say anything. They may not be able to read everything and fear asking a question that was already answered, repeating something that was already said, or generally appearing "out of loop." In the ISMHO group, one member described the flood of messages immediately after some cases were presented as "off to the races."

In the ISMHO group, we discussed some strategies for managing fast-paced activity. When setting the e-mail list to "digest" mode, a person receives all messages in one file rather than multiple messages, which some people find easier to read. The "Repetition is OK" item in the G&P message specifically encouraged members not to worry about joining in late for a discussion and possibly repeating something that was already said, though some members still felt uncomfortable with that possibility. It was suggested that someone be appointed as a moderator who could regulate the flow of messages. In some e-mail systems, it might even be possible to set-up a program that automatically controls the pace. It was also suggested that we create a delay period in which no one should respond for a specific period of time (e.g., 3 days) after the presenter sent the initial description of a case. That delay period could give everyone time to mull over the case before responding.

Although the delay strategy might prevent the "off to the races" effect, it could simply delay it a few days, and perhaps even magnify the effect by creating a pent-up of replies. The ultimate goal is to optimally even out the flow of messages, without unnecessary restrictions. Excessive attempts to pace the group removes spontaneity and personal choice. It also washes out the natural ebb and flow that is an informative aspect of the group's dynamics. Having fast and slow responders could also be an asset to the group. In fact, inviting people to discuss their reading and responding habits can yield useful insights into each other as well as the group process.

Learning to accept and even appreciate the unusual dynamics of e-mail list communication may help ease some member's concerns about how to participate. The conversation often proceeds more like free association and brainstorming, rather than a linear, logically constructed dialogue. If the group can establish a norm of acceptance about people jumping in at seemingly random points, possibly repeating what was already said, engaging in non sequiturs, feeling lost - then the group will benefit greatly. All of these things can be viewed as unique and potentially creative aspects of e-mail groups, rather than as detriments.

One useful element of structure involves the conclusion and introduction of cases. The facilitators should take care in helping the group wind down and wrap up the discussion of a case. Messages with subject titles that clearly indicate the end of one case and the beginning of another will help alert the members to transitions, as well as provide useful boundary markers in one's archive of messages. The facilitators may need to use backchannel e-mail to remind and guide presenters into the start of their case presentations.


The Dynamics of Text Discussions

Many ingredients of an effective e-mail case study group overlap with those of the in-person variety: good leadership, respect and cooperation among members, a sensitive management of the group's social-emotional processes, and a professional attitude about clinical work. Other aspects are rather unique to text-based discussions. For those who are new to e-mail groups, the process will seem unfamiliar and perhaps confusing. With more experience, members can adapt to this unique environment and come to see the e-mail group as a rather fascinating experience, with many subtle, complex features that are not immediately obvious at the start - features that will shape how the cases are presented and perceived. For this reason, it's a good idea to encourage the members to discuss the process of the group itself. In the ISMHO Case Study Group, we created a "format and process thread" devoted specifically to a wide variety of meta-discussions, including software and hardware problems, the experience of e-mail communication, observations about the group process, countertransference reactions, and suggestions for improving the group. Running parallel to the case presentations, this format and process thread can uncover important insights into the group process and the cases presented.

In this article so far, we've already touched on some of the unique aspects of group e-mail communication. Here we'd like to more clearly outline some of those features, noting some implications for the case study group:

The TextTalk Style: Although technologically savvy members can integrate pictures and links to multimedia resources into their messages, most people will simply use typed text to communicate. People vary in how comfortable they feel and how skilled they are in expressing themselves through writing. They also may vary greatly in their ability to understand and psychologically connect to others via reading, what we might call "e-mail empathy." In a self-selection process, the writing/reading barrier will prevent some people from entering the e-mail world completely. It's even possible that there is a difference in cognitive style between people who love to communicate with written words and those who prefer in-person conversation. People are skilled at one and not necessarily the other. It also may be helpful for the group members to discuss how the TextTalk style of discussing clinical cases relates to the method of actually doing the clinical work, which could be either verbal or text-based (as in e-mail therapy).

Creative Keyboarding: One important aspect of effective e-mail communication is the expressive use of keyboard characters and text formatting. Experienced e-mailers have developed a variety of keyboard techniques that 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 examples include emoticons (usually "smileys" and "winkys"), LOLs, parenthetical expressions (pointing finger into the air), voice accentuation via caps, and trailers to indicate..... pauses in speech.

Subject Titles: The subject line of an e-mail message is a tiny microcosm unto itself. When used effectively, it enhances both the organization and expressiveness of the conversation. Most often it's employed simply to summarize or introduce the major idea/s contained in the body of the message. Experienced e-mail users understand the more subtle techniques for communicating meaning and emotion in the titles they bestow to their e-mail. The subject line can lead into, highlight, or elaborate a particular idea in the message. It can ask a definitive question, shoot back a definitive answer, joke, tease, prod, berate, shout, whisper, or emote. A creative application of caps, commas, slashes, parentheses, and other keyboard characters adds emphasis and complexity to the thoughts and emotions expressed.

While unavailable in face-to-face supervision groups, the subject line gives presenters an opportunity to creatively entitle their presentation, which forces them to capture the essence of the case. In order to maintain organization in the e-mail archive, people responding to a particular case should probably stick to the original presentation title by using the "reply" button. Unfortunately, this precludes the possibility of having interesting threads, each with different subject lines, embedded within the discussion of the case. If the original title is not too long, it may be possible to add on subtitles that will divide the discussion into subthreads, e.g., "Re: The Wolfman (family dynamics)"

Threaded Discussions: Several topics of conversations can be running simultaneously, hopefully each one clearly marked by a distinct subject title for the messages. Usually this can be very efficient, with some very interesting patterns of parallel process emerging across the threads. Threads with casual, friendly conversation - including those that mention personal experiences, holidays, and current events - will create bonding in the group, as well as an anchor to real world events that helps ground the group in the otherwise timeless, spaceless realm of cyberspace. Too many threads, especially when poorly organized by overlapping or non-descriptive subject titles, can create confusion. Busy independent threads running in parallel to the case presentation may draw attention away from that presentation.

Quotes and Multilayered Messages: An advantage of e-mail discussions is the ability to quote parts or all of what others said in their messages. Often it's a very effective strategy - especially when messages are short, which makes it obvious what the person is replying to. Inserting a reply at the top or bottom of a long quoted message may be perceived as laziness or indifference - as if the person simply hit the reply button, typed a response, and clicked on "send." The recipient may not be sure exactly what part of the message the colleague is reacting to, and may also be annoyed by having to download an unnecessarily long file. Sticking a reply at the end of the lengthy quoted message can be particularly annoying because it forces the person to scroll for several screen lengths, looking for the reply. Generally speaking, quoting the entirety of a hefty message may not come across as a considerate and personal response.

The alternative is to select out and respond individually to segments of previous messages. It takes more time and effort to quote segments rather than the whole message, but there are several advantages. People may appreciate the fact that you put that time and effort into your response. It makes your message clearer, more to the point, easier to read. It may convey to your partner a kind of empathic attentiveness because you are responding to specific things that he or she said. You are letting the person know exactly what from their message stood out in your mind. Replying to several segments can result in an intriguingly rich e-mail in which there are several layers of discussion occurring at the same time, each with a different content and emotional tone.

There are potential pitfalls. Incorporating cited text from several other people's messages into one's own message sometimes gets confusing. It's hard to tell who said what. To counteract this complication, use different colored text and/or styles to designate different voices. Incorporating more than three voices into the message will probably befuddle people no matter what technique is used. In flame wars, you often see people citing more and more of what the opponent said, using it as ammunition to launch counterattacks. A series of point-by-point retorts becomes a verbal slicing up of the foe, almost as if it reflects an unconscious wish to "tear up" the person by dissecting his message. Often the attacker wants to legitimize his arguments by citing the opponent's exact words, as if the citation stands as concrete, unquestionable evidence. However, it's very easy to take sentences out of context, completely misread their emotional tone, or juxtapose several segments extracted from different parts of the other person's e-mail and then draw a false conclusion from that forced composite of ideas - what turns out to be "cut and paste reality" (see Fenichel, 2000). Even when people are not debating and have the best of intentions, an excessive dissecting and "vacuuming down" of a message may feel overwhelming, interruptive, evaluative, or inconsiderate to the other person.

Missing FtF Cues: In the typed text of e-mail, you can't see and hear other people. All those subtle voice and body language cues are lost, which can make the nuances of communicating more difficult. Skilled writing and creative keyboarding help a great deal, but ambiguity may persist. What exactly did the other person mean by that? The partial anonymity resulting from missing f2f cues also leads to the well-known online "disinhibition effect." People may be more honest and intimate - or more hostile - than they would be in an in-person meeting. This disinhibition could result in a productive discussion of clinical cases where therapists candidly discuss their work (including countertransference reactions) while colleagues offer straightforward feedback. Unfortunately, the atmosphere also could become too expressive or critical. The combination of ambiguity and disinhibition forces group members - especially the facilitators - to carefully track and regulate the group process. Politely asking colleagues for clarification is important. The facilitators also may need to communicate via backchannel e-mail to discuss the group's dynamics and reality-test their own perceptions. At critical points, they may also need to privately e-mail some group members to offer support, clarify issues, or work through potential problems.

As Howard Rheingold has noted, the motto "assume good will" can go a long way in helping people endure the ambiguity of text communication that causes them to perceive negative meaning in their peers' messages. That motto might very well be a staple of a case study group's philosophy.

Asynchronous Interaction: Because e-mail discussions do not occur in real time, people have the opportunity to think, evaluate, and compose their messages before hitting the "send" button. Some group members will take advantage of this convenient zone for reflection. Some may not. Carefully composed versus spontaneous messages have their respective advantages and disadvantages. An organized, well-edited message can be easy to read, considerately concise, on-point, and empathically sensitive - but it could also come across as rigid, unfriendly, or over-intellectualized. Messages with spelling errors and a slightly chaotic format can demonstrate an informal, friendly attitude - as if the person is willing to be "off the cuff." However, it might be perceived as unprofessional. Whether a more professional or a more casual approach is needed will depend on the atmosphere of the particular thread, as well as the norms of the group. Much of the time an effective message is one that strikes a balance between spontaneity and carefully planned editing.

Peer supervision creates a climate of vulnerability. People may feel they place their reputation and pride at risk when discussing their cases or offering feedback. Emotions may run high. Here asynchronicity comes to the group's aid. An important piece of advice to the members is the 24 Hour Rule. Drawing on the skill of self-reflection that many clinicians have cultivated, take notice of when you are experiencing an emotional reaction to a colleague's message or the group process. Compose a reply if you wish, but set it aside for a day or so. When you return later on to read the e-mail exchanges, the situation may feel quite different. Being in a different and often less emotional state of mind, your colleagues' messages may take on a very different tone and meaning. It's a perfect opportunity to revise your reply in order to say, with more forethought, exactly what you want to say.

Keeping an Archive: A big advantage of the e-mail group is the ability to create an archive of the messages, thereby preserving a complete record of the discussions. Paying special attention to the subject titles of messages will help keep the archive organized. In particular, encourage presenters to create pithy titles for their cases while other members use the "reply" button in their responses in order to retain that title. Short titles will allow space to add on subtitles for creating subthreaded discussions. Some e-mail programs enable the user to alter the color or in some way label messages, which comes in handy as a way to visually highlight or categorize messages (e.g., the initial message that presented a case, backchannel e-mail, important notices, etc.)

Going back to reread messages helps refresh one's memory. It also helps detect countertransference errors in reading and memory, as well as yields important insights into the group process. In fact, simply scrolling down the list of messages in one's archive - or sorting the archive according to subject title, date, author, and even file size (features offered by many e-mail programs) - can be an enlightening experience. How many messages were there per case? How many times did each person post to the list? How did the flow of subject titles change over time? Interesting patterns emerge that shed light on the cases and the group process. As psychoanalytic clinicians are fond of saying, "it's all grist for the mill."

Communication Mishaps: As useful as e-mail can be in creating a unique environment for a group of people to meet, it is not without its flaws. Sometimes humans inadvertently produce the errors, sometimes the machines slip up. Messages are delivered out of chronological order, arrive without any content, or simply get lost. Attempts to creatively format a message get washed away or translated into splatterings of glitches. Unreliable ISPs leave members stranded. Usually, the noise in e-mail communication is well within an acceptable range. Feedback among group members - as in a "format and process" thread - will resolve many problems and keep others under control. To cope with the situation of people unexpectedly becoming disconnected from the group, encourage members to develop a "safety contact" - a member they can reach via some other channel of communication in order to relay their messages to the group.


Beyond Text Talk

There are thousands of discussion groups on the internet. Members come and go. Groups fizzle out. New ones appear every day. What makes a particular group thrive in such a climate? Establishing a group with a unique and valuable purpose, recruiting inspired members, creating a specific structure that encourages people to participate, empowering members to offer feedback to improve the group, all help. In an online clinical supervision group, members can be sufficiently motivated by discussions in which they receive support, good advice, and new knowledge.

Sometimes the group may need more than just text talk. Having the members work together on creating a specific product gives the group something to show for its efforts. A project with a tangible outcome rallies morale and a sense of accomplishment. It helps center the group's identity on a specific achievement. For example, the ISMHO group together prepared a set of guidelines for establishing a person's suitability for online therapy. A group collaborating via e-mail on a writing project is a challenge - and a topic for another whole paper - but it can be done effectively. Members of the ISMHO group also worked together on presentations at professional conferences, which gave them a chance to meet in-person.

This idea about meeting in-person points to another important issue about moving beyond text talk. Although e-mail works well for establishing a group, the interpersonal relationships within it and the group as a whole will be strengthened by communication via other pathways. Encourage members to talk by telephone and in-person. A group's cohesion is greatly improved even when only some of its members know each other face-to-face. If the whole group cannot meet synchronously in a face-to-face setting, then try an online chat meeting. In its studies of online clinical work, the ISMHO group often discussed how the integration of different online and offline modes of interaction can improve communication, intimacy, and bonding.

Even with very good conditions, an e-mail group over time may lose its energy. In general, online groups tend to have a short shelf life. They tend to fizzle out with messages becoming few and far between, and then stopping completely - often without anyone saying good-bye. As clinicians well know, people tend to avoid termination. Online, where there are none of the usual boundaries of time and space and no face-to-face contact to contend with, it's almost too easy to disappear without bidding farewell. Clinicians also know the invaluable benefits of addressing termination issues. If the founders and facilitators of a group sense the waning of a group, the strategies described in this article should help in reviving it. But if they sense the end is in sight, they should prevent the group from slipping into that unsatisfying, unproductive vanishing act. Even if they receive few replies, the facilitators should encourage members to review the history of the group, evaluate the group's strengths and weaknesses, and say their good-byes.


See also in The Psychology of Cyberspace:

Psychotherapy and Clinical Work in Cyberspace


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