John Suler's The Psychology of Cyberspace
This article dated June 01 (1.0)
Assessing a Person's Suitability for Online Psychotherapy
A hard copy version of this article appears in CyberPsychology and Behavior, 4, 675-680, 2001
In the months before the turn of the millennium, the International Society for Mental Health Online (ISMHO) established its Clinical Case Study Group. Created and facilitated by John Suler and Michael Fenichel, this online research and training group is devoted to the discussion of psychotherapy cases and professional clinical encounters that involve the Internet. The creation of the group evolved out of the need for more in-depth explorations of clinical cases in which online life and interventions play an important role. The group's philosophy is that clinical work involving cyberspace sometimes will resemble traditional in-person psychotherapy, but also that the Internet has resulted in some very new clinical issues and a fascinating variety of unique intervention formats.
In its second year, the group discussed the various factors that might determine a person's suitability for online therapy. Because the group was not aware of any comprehensive set of guidelines for determining such suitability, it decided to create them. Although these guidelines are designed mostly with text-based therapy in mind (e-mail, chat), many of them apply also to other online methods of communication (e.g., internet telephoning, video conferencing). "Suitability" refers to a variety of factors, including the person's preferences regarding online therapy, how suggestible the person is within a particular communication modality, his or her skills in communicating within that modality, and the potentially therapeutic aspects of that modality for the person. Because there are many possible formats for online clinical work, as well as many different theories of psychotherapy, these guidelines are not intended to be exhaustive or definitive. Hopefully, clinicians will adapt these ideas to the unique aspects of each of their online psychotherapy cases.
While conducting the assessment, the clinician needs to keep in mind the ethical issues regarding online therapy, such as those described in the suggested principles of the International Society for Mental Health Online. As these suggested priniciples indicate, it's important to inform clients about issues regarding privacy, the potential benefits and risks of online therapy, and possible safeguards. The client's ability to understand this information and his/her attitudes regarding these issues could be important determinants of the client's ability to benefit from online therapy.
1. What communication methods are adequate or preferable for assessing the client?
The clinician has a variety of communication methods for conducting the initial assessment of the client: in-person, video-conferencing, phone, email, and instant messaging or chat. Clients may have a preference for this initial contact, which may in itself be of diagnostic significance. Clients interested in online therapy may prefer a text-only setting for this first contact. They may feel more comfortable in that setting, be more able to express themselves, or wish to maintain some anonymity. Clients' preferences need to be considered along with the potential advantages of conducting the assessment using different communication methods. Combining different methods during the assessment process will yield more comprehensive and qualitatively different information about the client's personality and behaviors. Face-to-face and/or phone interviews should be encouraged during the assessment phase, although these methods may not be absolutely necessary in every case. Assessment within the preferred medium may be sufficient if communication within that medium is accurate and efficient.
Assessing the client with the communication method that will be the medium for therapy is important. However, the clinician should consider the possibility that the client may benefit from therapeutic work in communication environments that are NOT his or her stated preference. It also is possible that the person may benefit from therapy that includes more than one environment (face-to-face, phone, email, chat, etc) - which means that the treatment will involve more complex variables regarding contact time and format than traditional in-person therapy. The client's preferences, skills, and attitudes regarding work within multiple environments will be important factors to consider.
2. How might the person's computer skills, knowledge, platform, and internet access affect the therapy?
The ability to benefit from online therapy will be partly determined by the client's computer skills and knowledge, especially if the communication setting involves installing and learning new software and/or hardware. If the person seems to communicating efficiently and accurately within the setting of choice, no further assessment of the person's skills may be necessary. If therapy will move to another setting, it is important to assess the extent to which an online client is able to effectively use the computer hardware and software at his/her disposal to communicate in a manner which feels natural and allows for nuance in describing and expressing oneself. Part of the assessment process might involve a trial stage in which the therapist and client test out the communication pathway between them, without yet having established a commitment to the therapy. Some questions to consider include the following:
-- Does the person demonstrate adequate knowledge of his/her computer system and internet technology?
-- Is the person motivated and capable to experiment with new communication environments and techniques?
-- Is the person's computer system compatible with that of the clinician?
-- What kind of internet access does the person have?
-- Where is the client accessing the internet (home, work) and does this present any problems regarding privacy or any technological difficulties (e.g., firewalls that limit internet activities)
-- If the client's internet access is problematic, are there viable alternatives (e.g., a web-based e-mail account)
3. How knowledgeable is the person about online communication and relationships?
The ability to benefit from online therapy will be partly determined by the person's familiarity with the technique and psychological aspects of online communication. First-hand participation is valuable, as well as the person having read about the internet and talked to others about it.
-- What is the person's lifestyle in cyberspace?
-- What experience does the person have with communicating online?
-- If the person has online relationships or belongs to online groups, what have these social activities been like?
-- In what settings did these relationships develop and for how long?
-- What other activities does the person pursue online, and what is his/her attitude about life in cyberspace?
4. How well is the person suited for the reading and writing involved in text communication (email, chat)?
If the therapist will be working with the client via typed text, assessing the clients experience with reading and writing is important. A person's reading and writing skills may not be equivalent, but both are necessary for text-based therapy. Some people may prefer reading over writing, or vice versa, which could have a significant impact on text-based communication. Assess the person's motor and cognitive skills for reading and writing, as well as the person's psychological experience of these activities. What does reading and writing mean to the person? What needs do these activities fulfill? It may be helpful to discuss how the person's attitudes and skills regarding in-person communication compare to those regarding text communication. When assessing the person's suitability for text communication, it's important to remember that developing and enhancing the person's reading and writing skills may be intrinsic to the therapeutic process.
Because chat/IM is a different experience than e-mail, it's important to determine the client's skills and preferences regarding these synchronous versus asynchronous methods of communication, as well the person's potential to benefit from these different methods. It may be informative to ask the client to complete a writing exercise that is relevant to the type of online therapy being offered (e.g., a summary of the history of one's life, a description of a scene related to the presenting complaint, an essay about one's personality or family members, an objective description of a specific problematic behavior).
Some questions to consider during the assessment stage include the following:
-- Does the person like reading and writing?
-- What kinds of experiences has the person had with reading and writing?
-- What do reading and writing mean to the person?
-- Are there any known physical or cognitive problems that will limit the ability to read and write?
-- How well can the person type?
-- Does the person enjoy in-person and phone conversations. Why?
-- How does the person feel about the spontaneous, in-the-moment communication of chat/IM as opposed to the opportunity to compose, edit, and reflect, as in e-mail?
-- Might there be therapeutic benefits of using chat, e-mail, or some other method of text communication even though the person may not prefer that particular method?
5. How might previous and concurrent mental health treatment affect online therapy?
If the person has been in therapy before, this will have created some impressions and expectations of what therapy is like. It is important to assess how these impressions and expectations are influencing the person's attitudes about online therapy, especially if the communication method will be different than that used in the previous therapy. Inquire about what type of therapy it was, the therapist's style of intervention, the duration of the therapy, the goals and outcome. Compare these factors to what will be offered in the online therapy. If the person currently is involved in other online or in-person mental health treatments, how will this influence the therapy?
6. How might personality type, presenting complaint, and diagnosis influence the person's suitability for online therapy?
This is a complex topic that deserves more clinical research. A separate set of guidelines could be devoted to it. One basic issue is the level of care a person may require (see Stofle's description). People who need full or partial hospitalization with close observation and supervision may not be appropriate for online therapy. The level of care a person requires also may change over time, thereby requiring that the clinician assess the person's history of level of functioning, and then periodically reassess the client during the therapy. As a rule of thumb, severe pathology and risky behaviors - such as lethally suicidal conditions - may not be appropriate for online work. Tendencies towards poor reality testing and strong transference reactions may become exacerbated in text communication, thereby making them difficult to manage and potentially destructive to the treatment. People with borderline personality disorders often challenge the boundaries of therapy, which can be especially problematic in e-mail communication and when combining different methods of communication. The clinician may need to set very clear rules about when, where, and how therapy takes place. The structure offered by online therapy may attract people who experience problems with impulsivity, internal emptiness, splitting, and aggression which otherwise get acted out in the comparatively unstructured social world of cyberspace. More clinical research is needed to determine what types of significant pathologies might be treated online, and how.
Assessing personality disorders and types (antisocial, narcissistic, schizoid, avoidant, paranoid, depressive, manic, masochistic, obsessive-compulsive, histrionic, dissociative) may lead to valuable information about how these people react to various forms of online therapy. Will avoidant and schizoid people fare well in the potentially anonymous environment of text conversation? Will the projective mechanisms of paranoid people be overly exaggerated in text communication? Can people with dissociative tendencies benefit from work across communication settings - or by participating in online groups - or will such work amplify those tendencies by encouraging fragmentation into different online persona? More clinical research is needed to answer these questions and refine the assessment process.
Diagnostic testing can be valuable in assessing the psychopathological factors that might influence the efficacy of online treatment. If it's not possible to arrange in-person testing, online tests could be an easy-to-access supplement to the assessment interview. Hopefully, in the near future, professionally managed web sites will become available that offer diagnostic tests as an aid for online therapists. When using online tests, consider such factors as accessibility, affordability, user-friendliness, security of test results, compliance with ethical principles, reliability, and validity.
Of course, many assessment principles that apply to therapy in-person also apply to online therapy, but will not be reiterated here. In addition, the type of online therapy being offered (psychodynamic, cognitive, behavioral, humanistic, etc.) will determine the types of questions raised during the assessment stage. Whether a person might benefit from a particular style of therapy will be partly determined by how that style of therapy operates in an online environment.
7. How might physical and medical factors affect online therapy?
Does the person have any visual, auditory, speech, or motor disabilities, or any chronic medical condition? Is the person on medications? If so, how might these disabilities and medications affect the person's motivation for and ability to utilize online therapy? Some people are drawn to text communication, where there is no face-to-face contact, because they prefer to hide their physical appearance. Does the person present any signs that possibly indicate a medical condition that needs to be assessed in-person by a physician? Although text communication can be effective in assessing some psychiatric symptoms, other symptoms rely heavily on face-to-face cues (e.g. flat affect, motor retardation, degenerated physical appearance, slurred speech, tremors, etc.). If any auditory and visual cues are essential in assessing the person's condition, the clinician will need to contact the person by phone or face-to-face, or refer the person to another professional to complete the assessment.
8. How might cross-cultural issues affect the therapy?
It is very likely that the online clinician will receive requests for therapy by people from other countries and cultures. In these cases clinicians must determine whether communication will be significantly hindered by differences in language, and whether they are familiar enough with the person's culture in order to effectively conduct psychotherapy. Although cross-cultural issues are also important in in-person therapy, such issues may be unique and magnified in an online therapy when the client is living in a country that is geographically distant from the therapist.
9. What other online resources might be appropriate to incorporate into a treatment package?
A wide variety of potentially therapeutic resources are available online, including informational web sites, support groups, mental health message boards, self-help instruction, and experiential software. The assessment process might include an explanation of these resources to the client, and then a determination of whether the client is interested in or could benefit from them. The goal is to determine whether a multi-modal treatment plan might be therapeutic, and if so, what might those modalities be.
Online therapy will not be appropriate for all people seeking help. In these cases, the online practitioner should have the skills and resources to make appropriate referrals. When the practitioner determines that high risk or other factors indicate that a person is best served by seeking immediate treatment within his or her locality (e.g., for suicide prevention, medication assessment, etc.), such a referral or assistance in finding an appropriate referral should be provided.
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See also in The Psychology of Cyberspace:
Psychotherapy and Clinical Work in Cyberspace