John Suler's The Psychology of Cyberspace
This article dated July 00 (v1.0)

Hypotheses about Online Psychotherapy
and Clinical Work

The Online Clinical Case Study Group of the International Society for Mental Health Online is devoted to in-depth discussions of clinical work that involves the internet. The case studies include psychotherapy conducted exclusively via the internet (e.g., e-mail, chat), f2f therapy in which the internet is used for supplemental contact with the client, f2f therapy in which the client's activity in cyberspace is an important feature of the treatment, and interventions within online groups devoted to mental health issues. Listed below is an outline of the working hypotheses of the group. As the group continues to explore cases, this list will be revised and expanded according to the clinical data uncovered by these case studies.

1.The client's experience of text communication

1.1. The psychological meaning clients associate with "writing" will affect how they experience text communication with the therapist. Clients with conflicts about writing may prefer chat over e-mail.

1.2. The client's act of writing may in itself be therapeutic by fostering self-expression, self-reflection, and cognitive restructuring.

1.3 Clients with a history of chaotic relationships may experience text communication with the therapist as predictable and safe.

1.4 Clients who have been physically traumatized may be attracted to the silence and non-tactile quality of text communication.

1.5. Text communication may be helpful for clients who experience talking as a conflicted way to express themselves.

1.6. Some clients may experience text communication as a type of "merging" with the psyche of the therapist. Issues about separation and individuation may be important.

1.7. The therapist's e-mail can be a steady, supportive, reality-testing, ego-building voice "inside" the client's head - a benign internalization or introject.

1.8. Text communications (e.g., e-mail) can be a steady, ongoing effort to restructure a client's cognitions.

1.9. By using several sections of quoted text within a single message, multiple layers of dialogue can simultaneously address multiple therapeutic issues and multiple layers of the client's personality.

2. Effects of absent f2f cues

2.1. Lacking f2f cues, text communication can be ambiguous and an easy target for misunderstanding and projection.

2.2. Lacking f2f cues, text communication disinhibits clients, encouraging them to be more open and honest than usual, or encouraging them to act out.

2.3. A client's ambivalence about intimacy may be expressed and can be therapeutically addressed in text communication, which is a paradoxical blend of allowing people to be honest and feel close, while also maintaining their distance.

2.4. People struggling with issues about shame or guilt may be drawn to text-based therapy in which they cannot be "seen."

3. Effects of saved messages

3.1. Saved messages can be accurate data for reviewing the process of the therapy. They provide continuity and the opportunity for assessing and assimilating change.

3.2. Quoted text may be cited as "proof" of something someone previously said, but quoted text can be taken out of context and juxtaposed with other quoted text as a way to distort its meaning.

3.3. Saving text dialogues with a client can help therapists reduce errors in recall, some of which might be due to countertransference distortions.

3.4. Saved text read at different points in time will be interpreted differently based on changes in the client's or therapist's state of mind.

4. Asynchronous communication (e.g., e-mail, message boards)

4.1. The ability to delay responding in e-mail and message boards is useful in enhancing impulse control, self-reflection, and cognitive assimilation.

4.2. A client's issues about boundaries (separation, individuation) may be expressed and therapeutically addressed in asynchronous text communication which provides easy access to the therapist and is not restricted to the limits of a time-specific "session."

4.3. Some clients may experience the opportunity to send e-mail to the therapist as a kind of "holding environment." That contact can help clients with needs for object constancy (even if the therapist does not reply to the e-mail).

4.4. The therapist can use e-mail to be present "in vivo" with the client as a way to monitor and guide the client's attempts to understand and modify their behavior.

5. Synchronous communication (e.g., chat, instant messaging)

5.1. Some clients may benefit from the spontaneity and specific temporal boundary that is involved in chat sessions.

5.2. Chat sessions create a point-by-point connectedness that enhances feelings of intimacy, presence, and "arriving together" at insights.

6. The client's expression of identity

6.1. The client's writing style and message format reflects his/her personality. Changes in style and format reflect changes in mood and thinking.

6.2. Some clients express their "true self" online, or believe they do.

6.3. On the internet, the ability to alter and compartmentalize aspects of one's identity involves dissociation, which can be detrimental or therapeutic.

6.4. The online name/s and identities that people choose for themselves reflects their personality dynamics and is a worthy topic for discussion in psychotherapy.

6.5. Imaginative environments on the internet can be used to do dream work or to therapeutically explore the client's personal fantasies.

6.6. Because the internet is international, the clinician needs to be sensitive to multicultural issues and may need to clarify, from the start, the cultural background of the client.

7. The client's lifestyle in cyberspace

7.1. A client's behavior, identity, and lifestyle in cyberspace (especially romantic relationships) may express hidden psychological issues. Transference reactions in those online relationships may be prominent.

7.2. With the therapist's help, clients can use online relationships and communities as a way to explore their interpersonal style and experiment with and rehearse new behaviors. What is learned online can be carried into offline living.

7.3. Role playing in online communities and relationships - including gender switching - can be a therapeutic way to explore and experiment with identity.

7.4. Online relationships can be used to systematically desensitize social anxieties and build social skills.

7.5. Socially anxious people may especially benefit from talking online with other socially anxious people. Meeting in-person may be an important developmental step for them.

7.6. Clients can express and explore themselves by sharing what they do online. A client's online "space" (especially a personal web site) is an extension of the client's psyche. It is an important therapeutic event when the clinician or client visits the other's online spaces.

7.7. Clients may experience text from their online relationships as actually being "pieces" of those relationships.

7.8. Elements of clients' cyberaffairs (especially fantasy elements) may reveal the problematic aspects of their marriages. Online cyberaffairs may sometimes enhance a marriage.

7.9. Behavior in cyberspace involves a simultaneous acting and observing of one's actions. This may be intrapsychically significant to some clients.

7.10. The therapist should encourage and work with the client's empowering access to online information and transformative experiences.

7.11. Clients may have easy access to numerous online resources and mental health workers. The clinician needs to assess and work effectively with a client's online help-seeking behavior.

7.12. As a way to avoid termination, online relationships and groups may tend to "fizzle out" by people gradually sending fewer and fewer messages.

7.13. Clients with schizoid tendencies may be attracted to the private "worlds" that can be created on the internet.

8. The relationships between in-person and online therapy

8.1. Online therapeutic interventions can be used as a stepping stone to f2f therapy.

8.2. Combining f2f contact with online contact of various types offers the client the ability to therapeutically explore and integrate different cognitive styles and modes of communication. Different channels of communication may work best for different people.

8.3. Online support groups can be a valuable adjunct to psychotherapy.

8.4. Some important aspects of a client may be obvious in-person but almost invisible online.

8.5. Consistently, patiently,and empathically encouraging a client to seek f2f therapy can itself a form of online therapy.

9. Couples and family work

9.1. Some couples or family members may be able to communicate more effectively via e-mail or chat than in-person.

9.2. Using e-mail, a couples therapist can become an in vivo presence and catalyst for change.

9.3. Elements of clients' cyberaffairs (especially fantasy components) may reveal the problematic aspects of their marriages. Online cyberaffairs may sometimes enhance a marriage.

10. Working with online groups

10.1. Online groups devoted to information and support regarding mental health issues benefit from having rules about appropriate behavior, effective tools to enforce the rules (e.g., the ability to block people from joining the group), and a knowledgeable and confident leader who has appropriate technical control over the environment.

10.2. The objectives of the clinician managing an online group and of the business that owns that environment may not always be compatible.

10.3. The cohesion of many online groups is intrinsically weak due to the traditional cybercultural assumption that one can join or leave, respond or not respond, as one wishes. This effect may persist even in small and/or closed support and therapy groups.

10.4. People who "lurk" in a small online group can become a target of projection that might disrupt the group. People not even knowing if the person is consciously present disrupts the boundary of the group and creates distrust.

10.5. In small online groups, non-responding (lurking) tends to snowball. When people don't receive a reply, they tend not to post another message.

10.6. In an online group a person may use "multi-tasking" to carry on several relationships simultaneously - a process that may be dissociative and counterproductive, or integrative and therapeutic.

10.7. People with dissociative tendencies may act out in online groups by assuming different identities - some of them antagonistic, some not. A person may use different identities for the purpose of "splitting" relationships with others.

11. The therapist's issues

11.1. Some clinicians (and clients) are more sensitive in detecting the meaning and mood expressed "between the lines" of text communication. There is a type of empathy unique to online work.

11.2. Because text communication is less efficient than speaking, clinicians may be tempted to move faster by giving advice or "solving problems."

11.3. If clinicians are active in a variety of online groups and sites, clients may have easy access to information about them and may coexist with them in these spaces. Traditional ideas about "therapy boundaries" may need to be reexplored.

11.4. The equalization of status that tends to occur online may result in a decreased perception of clinicians as "authorities." The clinician may be seen more as a consultant who provides information and guidance in the design of a transformative program. "Twinning" relationships between the client and therapist may be important.

See also in The Psychology of Cyberspace:

Psychotherapy and Clinical Work in Cyberspace

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