John Suler's The Psychology of Cyberspace
This article created Aug 01; revised March 04 (v1.2)


The Future of Online Psychotherapy and Clinical Work

Other versions of this paper were presented at the 2001 Conference
of the American Psychological Assocation; and published as
Suler, J.R. (2002). The future of online clinical work.
Journal of Applied Psychoanalytic Studies, 4, 265-270.

Allow me to start off with a joke that I sometimes tell at conference presentations and in articles I write. I made it up myself, so be forewarned! I think I have little talent for creating truly funny jokes. Most of the time when I deliver it, a few people casually chuckle and some just stare at me. But I persist because I think the joke is interesting. And so, at the risk of my ruining my comedic reputation forever, here I go:

How many clinicians does it take to do computer-mediated psychotherapy?

None. The computer can do it all by itself.

OK, so I'm not Jerry Seinfeld or Rodney Dangerfield. Why do I think this joke is interesting. Two reasons. First, like many jokes, it points to a sensitive issue. Are we worried about computers taking over and ruining things for us? Will really crappy computer-mediated psychotherapy replace the tried and true methods of traditional psychotherapy? Well, we could certainly make those arguments and it's something we should be on the lookout for. On the other hand, the joke suggests that big and interesting changes are coming right at us. Will computers someday actually do psychotherapy? Well, even if we insist NO, what will be possible given all this new technology? People are already doing psychotherapy in cyberspace right now. So what's next? Where is this all heading?

That's the important question I'd like to address here. I'm going to take out my crystal ball in order to predict the future of online clinical work. Now, my fortune-telling skills are probably about as good as my ability to write a good joke, so maybe I should modify that statement. I'm going to talk about what I think might happen in the future, or maybe what I'd like to see happen in the future. And to a large extent I'm basing these predictions - or expectations - on issues discussed in the International Society for Mental Health Online (ismho.org) and, especially, its Clinical Case Study Group . It's a group that Michael Fenichel and I created several years ago - a think-tank, research, peer supervision group devoted to in-depth discussions of online clinical work of all shapes and sizes.

So here's the first word that appears in my crystal ball. It probably comes as no great surprise to anyone who understands psychotherapy. SPECIALIZATION. We are going to see people specializing in different types of online clinical work. Right now the focus is mostly on individual psychotherapy conducted via e-mail. This is what many people call "e-therapy." It's can be a very important, sophisticated method, usually based on a short term, psycho-educational model. There are obvious as well as quite subtle pros and cons. The e-mail specialist is going to fully understand those pros and cons and know how to work with them. There may even be specializations in different therapeutic approaches conducted via e-mail - psychoanalytic, cognitive, behavioral, humanistic, etc.

People may also specialize in an interesting intervention that we discussed frequently in the Case Study Group - the one-shot e-mail reply to people who request help. If you're a clinician with an online presence - say you have your own web professional web site - you're going to get requests, perhaps many requests out of the blue from people who want help and advice, sometimes desperate people. How do you reply to them in just one e-mail message? Skeptics say that this isn't psychotherapy, that it's more of an "Ann Landers" approach to helping people. Maybe so. But I'd like to speak to Ann Landers to find out how she does it. I'm not sure that we online clinicians would intervene the same as she does, but I do know one thing: It's not as easy as some might think. It takes quite a bit of skill to reply effectively. Then there's also the challenge of helping people in two, three, or four e-mail exchanges - a message-limited approach that is being adopted by some online clinical centers. How do you boil down psychotherapy to these packets of highly concise, written interventions? It's surely an area of specialization.

Other than e-mail work, we're going to see many other types of text-based specializations. For example, there's chat therapy, which isn't asynchronous like e-mail, but rather synchronous. At first glance it seems like a small difference, but the real-time aspect of the interaction between client and therapist dramatically changes the expertise required. Then there are mental health message boards which require a special knowlegde of support groups, group therapy, and community psychology. Group therapy via e-mail or chat are other possible specializations. People love to role play and experiment with their identity in cyberspace, so yet another expertise will be the creation of imaginary, text-based environments in which people participate in therapeutic fictional scenarios (see the Post-Modern Therapy web site). There are thousands of online communities with different formats, philosophies, and purposes. They weren't specifically intended to be psychotherapeutic, but for many people they are. In those communities people experiment with relationships, try out new ways of behaving, explore new dimensions to their identity. It's a potential gold mind for clinicians who want to specialize in consulting with and guiding clients in using their lifestyles in cyberspace as a personal growth experiment. In what looks like a kind of narrative therapy, people are publishing personal journals or diaries online. They create web sites where they reveal and explore themselves. They get and give feedback to other people who are doing the same thing. Might clinicians develop an expertise in learning how to use this phenomenon therapeutically with their clients?

Almost all of these specializations I mentioned so far involve mostly text-based communication. The Internet offers more than just that. Obviously, there's video-conferencing, which is an attempt to recreate the in-person, f2f psychotherapy session. We also have this fascinating ability to create imaginary, multimedia environments. We already see VR being used in exposure therapy and in designing relaxation procedures. Might we also use VR in helping clients work through trauma? Could we do dream work in VR, or reconstruct and explore memories, or behavioral modeling and role playing, or psychodrama scenarios? Let's say a client relives a childhood scene at the dinner table, or experiments with telling off the boss at work, or lives inside Madeline Albright, Tony Soprano, or Bart Simpson for a day. All of these imaginary scenarios will be possible and such applications of VR might involve different specialty areas. Here's where my crystal ball gets hazy - hazy because its clouded by countless numbers of possibilities. We can't even imagine what might happen down the road in computer and Internet technology. As creative clinicians looking for new opportunities, we may not even know what is possible in the technical realm.

Emerging from that haze inside the crystal ball, a word does appear very clearly. It's the word INTERDISCIPLINARY. We can't rely on our own efforts in designing new computer-mediated approaches. We need to consult with experts in cognitive psychology, communications, human factors engineering, and Internet technology. They have knowledge we need. The computer and Internet experts will be able to tell us what technology is available. The communication and cognitive experts will help us understand some of the essential nuts and bolts of computer-mediated experience, like immersion and presence.

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 a comprehensive model of cybertherapy 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. Might the treatment for that client involve a package of several types of online interventions and experiences, with the package designed and conducted by the interdisciplinary team?

Right behind the word "interdisciplinary" in my crystal ball, I see another word forming. It's NETWORKS. The Internet is all about connecting people and resources. If we're going to create these interdisciplinary teams, then obviously the members are going to be working with each other via the Internet, through e-mail, message boards, chat, social network systems, and most likely person-to-person systems. The therapeutic environments they construct for their clients will be part of that network. I know this is a very tall order, but hopefully, ideally, we'll see cooperation among different clinical networks rather than competition. One important feature of these networks will be the linking of online and in-person services. Cyberspace therapy is great, but let's face it: in-person treatments will be best for many clients, and some treatments will only be possible face-to-face. Here's a scenario that illustrates a perfect marriage of the f2f and online clinical worlds:

Mr. Smith, who lives in Denver, emails an online clinical center that operates out of Sydney. The case manager from Atlanta working at that center does an intake with Mr. Smith. He interivews him via email, conducts a video-conferencing session with him, does some online psychological testing, and decides that Smith might really benefit from EMDR or Somatic Experiencing Therapy. He sends Mr. Smith to some web sites with information about those therapies, as well as other treatments for trauma. Smith is interested in EMDR. The case manager checks the network directory, finds seven certified EMDR clinicians in Denver. In an asynchronous user-to-user meeting, the case manager and the 5 EMDR clinicians share information and video clips about the case. Three of them are interested in working with Mr. Smith. The case manager sends the web site addresses of the three clinicians to Smith. He checks out their site and decides to phone one of them. Soon thereafter, he begins f2f work with that clinician, who also happens to use intersession email and VR in his EMDR treatment.
That's the kind of scenario I'd like to see in the future. And in it I see another theme emerging from my crystal ball - EMPOWERING OF THE CLIENT. The Internet enables us to easily, efficiently offer information to clients. It enables us to easily and efficiently present the client with choices. Mr Smith receives a little bit of a education about therapy. He participates in the decision-making process. In some cases, the empowering of the client may even go even further. In traditional forms of therapy the clinician is placed at the center of the healing process. Clinicians administer a treatment or play a crucial role in creating a therapeutic experience. Many forms of online psychotherapy will similarly place the therapist in a strategic position for controlling the treatment process, but 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, social networks, assessment and psychotherapeutic software, and comprehensive self-help programs - not to mention the potentially therapeutic nature of online relationships and communities as social microcosms. In the role of consultant, the professional might help a client design a program of readings, activities, and social experiences that addresses his or her needs. In programs like eQuest, 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.

Hold on! I see something else emerging in the crystal ball. It's fuzzy, but I think it says A THEORY OF CYBERTHERAPY. If I interpret this correctly, I think it means not just a specific theory of e-mail therapy, or the VR treatment of phobia, or how to manage a mental health message board, but rather a global theory, a meta-theory, if you wish, that provides an overarching framework for understanding the many fascinating facets of computer-mediated clinical work. I have to say that I agree with the crystal ball on this one. I believe strongly in this need to develop a Big Picture theory of cybertherapy.... But what kind of theory?

In my article about computer-mediated psychotherapy, I describe this theory as one that looks at the elemental features of computer-mediated communication. I've always shuddered whenever I heard people throwing around this quite chic and trendy philosophical term, but now I find myself in the position of using it. So there must be something to it. We need a theory that "deconstructs" the therapeutic relationship or experience into its intrinsic communication components, and helps us understand the pros and cons of those components. These are the kinds of questions that will guide us in that analysis:
- Does the relationship or experience occur in real time or in an asynchronous frame. If it's asynchronous what are the effects of varying the delay between exchanges?

- Does the relationship or experience involve communication via text, or are visual images exchanged, or combinations of the two?

- Does the relationship or experience involve auditory stimulation? If so, what types? Voice? Other sounds?

- Does the therapeutic relationship or experience rely on real identities and real environments, or imaginary ones?

- How strong is the presence of the clinician in the therapeutic experience? Might the therapist in some respects be invisible? Might the client in some respects be invisible? For example, if the communication involves video-conferencing, might the therapist not see the client or the client not see the therapist?
These are just some of the elemental features. I think we need a theory that guides us in understanding when, how, and for whom these features are therapeutic, and also what combinations of these features are therapeutic for which people. We're looking for a theory that helps us analyze the potentially curative ingredients of different communication environments or communication pathways, and for deciding what environments or pathways are therapeutic for which clients.

I should emphasize that this theory does not replace traditional theories of psychotherapy, but rather acts as a supplement to them. In fact, this theory of cybertherapy could be used to help reexamine those theories in terms of the elemental features of communication. For example, why does the analyst sit behind the patient and therefore become partially invisible? In behavioral rehearsals, Gestalt dialogues, or psychodrama, what are the pros and cons of using imaginary versus realistic scenes? In the many forms of therapy that work with mental images, what are the advantages and disadvantages of focusing on these sensory experiences compared to dealing with language, verbalizations, and text?

There's one more word that my crystal ball wants to offer up, and it's AUTOMATION. Here's where I circle back to that joke about how many clinicians are needed to do computer-mediated psychotherapy. Might it be none? Can computers do it alone? One important elemental feature of clinical work in the next millennium will be this potential for automation. A wide range of clinical tasks might be conducted by software alone - assessment and psychological testing, structured behavioral and cognitive interventions, self-help approaches. Many of these programs already exist. Here's a very simple example. Some e-mail programs have an emotion filter. It detects your use of harsh language in your outbox mail, sets off a warning, and asks you if you want to reconsider editing the message. A very simple automated task, but think how therapeutic it might be as a component of a treatment package for someone with impulsive control problems.

We're going to see more and more of this kind of software, which is only going to get more and more sophisticated. We can laugh at the old Eliza program and how clumsy it was at doing a talking-cure, Rogerian therapy. But AI technology is becoming very sophisticated. AI programs are getting much better at detecting subtle aspects of human language. Will an AI therapist be as good as ftf therapy with a flesh and bones clinician? In most cases, no. No matter how sophisticated they are, machines will have a very hard time replicating the subtle human eye for understanding the complexities of human experience. But these machines can be very helpful as adjuncts and supplements. In some cases they may even take the lead role in basic counseling with a human clinician supervising them. I can see the sign on the clinic door:

Clinical Associates:

Arty Clarke, Psy.D.
John Suler, Ph.D.
Hal 9000, A.I.



O.K. Another not-so-terribly-funny joke. I guess the point I'm trying to make is this: There's a tendency to worry that as we get further and further into technology, humans will become more like machines. Hopefully the reverse is true. Maybe machines will gradually become more human.



See also in The Psychology of Cyberspace:

Psychotherapy and Clinical Work in Cyberspace


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