American Psychological Association

109th Convention
San Francisco, August 24-28, 2001


[2001 Cyberspace Odyssey]
Photo: (Left to Right) Nancy Kalish, John Suler, Michael Fenichel
4132 Symposium: 2001: A Cyberspace Odyssey - Integrating the Internet into our 21st Century Lives

This was of course a very special presentation for this writer, being the chair and having a chance to present with some of the people I most respect, in front of a great audience at the APA's 2001 Convention. My own presentation will be described here in a way I hope will give you a sense of what it was like to be there. I sought to introduce a taste of how we are integrating technology into our lives by weaving various digital mediums into a rapid-paced tour of the Internet. The presentation utilized a live Internet connection (which led to an interesting and spontaneous discovery) as well as .html and powerpoint "slides", and some digital photography of hard-copy magazine covers about Life Online. (Dr. Suler, btw, is a master of the web graphic, in his own rite!)

Because of the many requests I've gotten for some type of "handout" to replicate my presentation I've sought to weave the multi-media into the following *online* presentation, for you. I hope you enjoy it, and apologies to my co-presenters for not having taken very extensive notes on their segments, though I'll summarize as best I can. Actually, I was quite busy praying to the technology gods.... Fortunately, things went very well, though we could have used another hour! :-)

Abstract: Internet-facilitated communication is undeniably changing our way of life and becoming integrated into the daily lives of psychologists and their clients (and students). This symposium features a virtual tour through Cyberspace, and provides an in-depth look at Internet behavior. Panelists present ongoing projects, along with:


2001: A Cyberspace Odyssey
Integrating the Internet into our 21st Century Lives

Michael Fenichel, Ph.D., clinical psychologist, President of the International Society for Mental Health Online, and publisher of Current Topics in Psychology (this website), presented the following, approximately.

Overview/Introduction

(Visualize some powerpoint-ish bullets, vivid blue, and a few graphics such as computers in classrooms and bulleted statistics about Internet use.)

The audience/reader is asked: Does anyone here really doubt that the Internet has deeply touched the lives of us all? The communication revolution has affected our way of life, and this is a reality which has not escaped the healthcare/psychology/counseling professions. As practitioners, even in exclusively office-based practice we are virtually assured of seeing clients whose lives are influenced to a major extent, by time spent communicating or entertainment-surfing on the Internet. Think about teens, for a start. An overwhelming percentage of teens report that they "multi-task" while online, and favor real-time chat more so than do adults. (They also buy less, and spend less time online, because for them, it's just one more tool for communication, and they "don't know anything else", as one teen newspaper reporter explained.) And some people simply prefer reading books. Or chatting online. Or on the phone. Or texting. This is life in the 21st century.

Yes there are those (of all ages) too, who may have very rich lives, real or virtual, who are connected to others on the web, but whose lives *offline* are painful, and who may be among those most likely to be online looking for counseling, support, or knowledge for self-help via the Internet. Some do seem to become "addicted". Others effortlessly embrace the Internet as a tool for work and for social discourse, and have integrated computers and new communication technologies well, not giving the hardware a thought, and utilizing the tools with such natural facility that the computer becomes quite transparent.

Aside from treatment and support, there is also the increasing presence of distance learning and online course materials, as a part of, or type of, higher education (something discussed a few weeks ago on CBS' 60 Minutes). But exposure to computers and information/communication technology now takes place long before entering university. And technology helps us, literally, from birth on. Now, for adults in particular, a great deal of education is taking place through self-guided odysseys through self-help, support, and research sites, to say nothing of the large organizations such as APA who have been rapidly expanding online offerings for both members and the general public. All one needs to do is look around and we can clearly see the impact of the Internet in homes, at school, in our communities, and in the media... Even in our every day language and daily discussions. OK, so do we all agree that the Internet is definitely affecting and changing our lives? Good. :-)

Now when did this all happen? Here are a few socio-historical markers along the Internet highway, which reflect the evolution and revolution in Internet-facilitated daily life.

Classic Internet History
And as we enter the new century, 2001 sees technology affecting every day life in the form of Cell-phones, PDA's, texting, and other major evolutionary and revolutionary tools. With it, the technology brings new opportunities, risks, and benefits. Also, there are new challenges for clients and practitioners alike (e.g., privacy, virus anxieties, cultural threats). An image of a large hall full of Chinese citizens (just before this convention, July 21, 2001) accompanies Peter Jennings of ABC World News explaining that "...in China, the Government has shut down 8000 Internet cafes it says were promoting access to pornography and other sites considered subversive." This is one reaction to the power and potential of the Internet, by the world's most populous country,

The Internet is here, and it is a powerful force in people's lives, worldwide. This bit of history is to remind old-timers of how recently this global phenomenon has virtually exploded, while also being for the benefit of those relatively new to the joys of online experience. That's a"fast forward" view of just the past 2-3 years, to see how extensively our society and culture has embraced so many aspects of the Internet's potential for communication and information.

Just in case there were still any skeptics who don't believe online activity is here to stay, and pervasively affecting our way of life, some digital slides (from a digital camera) were presented, ranging from some recent scary newspaper headlines about Internet Fiends, to a front page magazine cover about fears of Internet worms, to some glossy colorful depictions of a brave new world for medical information. And yet it is important to acknowledge, as depicted in a cute cartoon [which I'm seeking permission to re-print], that despite all the benefits and potential of 21st Century technology, there still will be those who haven't yet become excited.

Sadly, btw, for those who haven't fully realized that the big dotcom bubble has burst, there was the sobering news this week that both The Industry Standard (best source of web metrics, imo), and Etherapy.com have folded operations, and Excite@home is also facing imminent demise as their faltering business faces abandonment by their parent company, AT&T. Not a good week for big business. But individual users are still here. (Wherever "here" is.)
 
Practitioners should note that there are new types of lifestyle-related issues which both online and offline psychologists will be presented with, even such things as "irrational fear" of computer viruses, or victimization by cyber-stalkers, or trauma due to escalated passions generated on a list-serv "flame war". At this point (and I'm happy to say I've obtained the artist's permission to share this), I used a second cartoon to illustrate both the risks and benefits of e-mail lists, one of our most powerful tools for sharing ideas and information within groups.

And now, live, or asynchronously live...

A Virtual Cyberspace Tour

At this point the presentation changed gears to a look at the present Internet landscape, as Dr. John Suler tuned up his crystal ball, ready to take us into the future.

A live web page with links to mental health sites representing a wide range of "psychology online" was used to facilitate a guided tour around the web. First came a look at several of the positive aspects being harnessed by psychologists and others, for education, self-help, treatment, supervision, etc. Some of the sites, such as the Google page, offer some interesting demographics, in terms of what languages and countries are seen on the web, what browsers are most popular, etc. One site ranks the most popular mental health sites online, the top nine. Do you think the top one is APA, or ApA? Think again... it is Queendom.com, which features self-administered "IQ" and "personality" tests. Another site on the tour is a user-friendly and pretty page about "Flowers for Algernon", which both describes the world of a friendly mildly mentally retarded individual, and gives a hands-on look at Rorschach testing. Geared for high school students to make psychology accessible. And more.

Then began a tour of "The Good, the Bad, and the Ugly". Note, please, I did not label or categorize the individual sites, but included both some very solid sites and some glaringly problematic sites in the hopes of engaging the audience in a discussion of such things of major importance as informed consent, identity and credentials of providers offering services, contingency planning for emergencies, and so forth. (These topics are well covered in other articles on this site.) My own site was offered as an example of something borne out of necessity, a self-built tool for locating resources and handouts for students and parents in school and clinic settings. It now features a huge variety of specific articles as well as mega-content websites for a closer look at a great many areas of interest to psychologists and mental health consumers. Other sites are primarily gateways for referrals, or tools to sell books, or public service offerings, or fee-for-service companies, charging all sorts of fees for all sorts of services. (Caveat emptor!)

One interesting surprise occurred, as the tour was stopping to see various sites with and without graphics of couches, and some of the megasites no longer in business or turned into other things... A site which has generated some controversy was visited, live, for the audience to see. Until a week ago it's main page was a promotion for the joys of unlicensed therapy. The intention was to let the audience comment. But as it happened, in just the few days since preparing this presentation and actually presenting it, the site changed. In fact, there was now a disclaimer that as of now the content is for "historical purposes" only, and there is a letter from a California State board ordering a response within 30 days (which had just past) as to why they were practicing without an apparent license to engage in marriage and family therapy. That's still up, and is a perfect example of where the cutting-edge grows fuzzy...

In response to several requests, you can now re-create the web tour, with this "handout" to be used only for educational purposes, at http://www.psychservices.com/2001handout.shtml

As you'll see, many of these sites simply offer information, or biographies of individual providers, which is a large segment of the web, with many private practitioners as well as group practices simply having an "online calling card". Other sites offer e-counseling, or therapy, or coaching, or whatever. Some of these may be inspirational, others may serve as good examples of why consumers need education and regulatory protections. At the same time it is clear that we have a continued need for increased research, graduate education, and continuing education for practitioners.

Welcome to the 21st Century!

Nancy Kalish, Ph.D., author and researcher into lost lovers and rekindled romances, advice expert to teens online (www.lovestories.com), and online message board hostess at www.lostlovers.com, presented an overview of how adolescents and adults interact with the Internet in the pursuit of new, or lost lovers. The power of the Internet to facilitate such efforts, is of course quite apparent. Almost everyone, it seems, also knows of someone who has had some type of "online romance". As Dr. Kalish noted, it is very easy to enlist online resources such as classmates.com or 411.com to search for lost friends or lovers. Once contact is made, well known factors such as disinhibition, and the power of "immediacy" can prompt rapid and intense formation of relationships.

Dr. Kalish described the research she did from 1993-1996, enlisting more than 1000 respondents in her effort to look at how people were faring after locating "lost lovers". What she found was a very high percentage (72% at the time of the survey) had sustained their newly re-found relationships over time, 78% for first loves. A follow-up in year 2000 found that these relationships are still quite stable for the vast majority. "But there are down sides" she noted. "Marriages are crumbling" as one or another spouse decides that the first true love is preferable to the current marriage. However, Dr. Kalish cited evidence to suggest that probably 1/2 of the marriages which break up after re-finding lost lovers "were in trouble" prior to beginning the searches for lost loves.

Dr. Kalish described how easy it is to begin the process which can lead to major life changes, with powerful consequences. It's simple to "just type in a name, do a search" out of curiosity. Then when one comes across the former love one wonders about "sending an e-mail seems innocent...[or] like typing to yourself, somehow it's not real.". The stories she's heard suggest that after some "innocent" e-mails, phone calls are next and "the angst begins". Even if the relationship seems wonderful, feelings of guilt, remorse about children, etc.... it can be a huge ordeal. Dr. Kalish feels her message boards are in fact "saving relationships" as people share their experiences, both positive and negative.

It's not only middle-aged spouses who find the Internet a powerful tool for changing or setting a course towards new or old relationships. Adolescents report that online communication is a perfect way of saving face or gathering courage to ask someone on a date, as rejection is far less embarrassing when it's not face to face. A recent Pew Institute study was cited, the findings suggesting that 25% of boys, and 10% of girls use e-mail for the purpose of asking someone out. There are dark sides of the anonymity as well, such as predators, but also some very helpful sites, including Rutgers University's Social Work schools' Sexcetera.com, where teens can anonymously seek vital and educational information about sexual issues. (She noted that gender issues account for a large percentage of teen suicides.)

Turning to the types of posts she sees on the teen site, Dr. Kalish noted that a majority of writers are aged 12-20, and a goodly number of writers tend to sign their name with something like "Confused". Typically, this is an accurate description, and so the website serves a useful function by facilitating reliable information as well a peer feedback and support.

Dr. Kalish sees the Internet being a well-integrated part of daily life among college students, as well. In particular, students are using lists for study groups, offering enhanced "flexibility of time". On the other hand, there can be a downside: "Students' uncritical use of biased and incorrect information". [I've heard this too, for a few years now: students tend to think if it's online, it's accurate information, and conversely, if it's not online, it doesn't exist!] On a personal note, Dr. Kalish commented that the technology, while a boon, can present a challenge for both students and teachers with cell phones going off left and right, and other distractions which are new to the classroom environment.

John Suler, Ph.D., cyberpsychology researcher, co-founder of ISMHO, professor of psychology, and the man who literally wrote the book on The Psychology of Cyberspace was next to present. Dr. Suler departed from our presentation of the recent past and current state of online behavior, to gaze into his crystal ball and see where what is already being explored may take us on our Cyberspace Odyssey into the 21st Century.

Dr. Suler began by looking at specialized skills which will be emerging, beginning with one of the most common types of communication online practitioners are seeing: the individual e-mail letter, requesting a single response. [This is an ongoing topic of discussion among members of ISMHO's Clinical Case Study Group, founded by Dr. Suler back in the 20th Century, and still going strong.]

Other modalities skillfully being employed will include:

Also appearing in the crystal ball are visions of interdisciplinary teams, working collaboratively via the Internet; networks-- chat, e-mail, and peer-to-peer; and linking of in-person and online services ("because sometimes face-to-face is desirable")

A case example:

Mr. Smith, who lives in Denver, emails an online clinical center that operates out of Sydney. The case manager from Toronto working at that center does an intake with Mr. Smith. He interviews 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 national network directory, finds seven certified EMDR clinicians in Denver. In an asynchronous user-to-user meeting, the case manager and the seven 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.

Sound far-fetched? Dr. Suler noted that now even smells are being shared across the Net... So "it's do-able, now... even giving out a mint!"

Proceeding to highlight the therapeutic potential of using the Internet, maximizing therapeutic options while empowering the individual client, Dr. Suler proceeded to outline ...

A Theory of Cybertherapy

In an effort to look at the "elemental features of computer-mediated communication and relationships", Dr. Suler argues that "we need a theory that deconstructs the therapeutic relationship into it's fundamental components". In so doing, we can then look at the unique ways in which online work presents both opportunities and challenges. For example, in assessing the effect of asynchronicity, invisibility, etc.... "We need to look at what features are therapeutic and what combinations are therapeutic." Some of the major elemental features which need to be considered are the dimensions of:

synchronous / asynchronous
text / sensory (visual, auditory)
real / imaginary
present / invisible
interpersonal / automated


In taking a brief look backwards, Dr. Suler recalled the relatively primitive automated "therapy" program, Eliza. He contrasted this with some of the newest software technology which is now available to consumers, complete with Artificial Intelligence engines, such as the Eudora e-mail program which now has very sophisticated "emotion filters" to help protect against precipitous responses which might be misunderstood across Cyberspace.

As Dr. Suler began sharing visions of year 9000 A.D., he looked back and paid tribute to the once-future voice of 2001: Our friend Hal, who first introduced us to the notion of supercomputers talking to us, as we enter a 2001 Cyberspace Odyssey...

And returning full circle to current issues effecting Psychology online,

David Nickelson, Psy.D., JD, director of Technology Policy and Projects for the American Psychological Association, addressed the state of affairs present and future, as he sees it from an ethical, legal, and practice point of view. Dr. Nickelson also spoke about the consumer point of view, noting APA's development of the DotComSense brochure [retired in Aug. 2004] and how APA is now moving in many new ways to facilitate practitioner and consumer comfort with the potential and risks of technology.

Dr. Nickelson identified some of the key issues which psychologists are discussing and addressing:
In terms of privacy and security, Dr. Nickelson noted that one of the effects of the new HIPAA regulation (that's the Health Insurance Portability and Accountability Act) is going to be a change from paperwork to paperless filing, which will give an edge to those already comfortable working online. He believes the Act is going to "push us all" into the age of digital office management

In terms of reimbursement, here too our nation is increasingly acceptant of online services, with Medicaid now accepting billing for online work in at least 13 states. Medicare is moving towards a fee-for-service model which already includes reimbursement for individual psychotherapy covered under existing CPT codes. What about insurance coverage? This was a question from the audience. Dr. Nickelson explained that APAIT, and likely the other insurors, are basically concerned that practitioners practice "within your scope of practice", and then coverage does include online work, if one is licensed to practice, and competent to do what one is doing.

The issue of licensure continues to be the 'sticky wicket', as there continues to be uncertainty about jurisdiction over transient Internet communication. (Where is the Internet?) Dr. Nickelson noted that despite some very conservatively interpreted regulations restricting any and all practice, some believe that even in the state of California, temporary practice should be recognized as acceptable under a Model Act (ASPPB) which allows for up to 30 days of practice by a licensed healthcare professional in a state other than one's own, if training and licensing requirements in the home state are considered "equivalent".

Interestingly, in response to an audience question, as to whether it's really true that California alone is enforcing a particularly restrictive stance against psychologists who seek to occasionally consult from their own offices (wherever) with a California resident, Dr. Nickelson replied (you're hearing it here first!) that APA has in fact asked the psychology board of California for clarification "true or false" that they will refuse to make any exceptions such as permitted under the ASPPB model bill. There has not been any response as of yet, but when/if one comes, it will be shared with members.

Dr. Nickelson gave some other examples of how things differ across the States. For example, in Nebraska, PA's can be supervised exclusively online.

Despite the potential for psychology, and ubiquitous use of the Internet by consumers and practitioners, Dr. Nickelson noted that under APA's new ethics code (in process), things will not change, the reason being that "our core values have not changed". Ethical practice is considered to be ethical online and off. Competency, informed consent, etc., are just as applicable across modalities, and the committee writing the revisions believes that just as past references to paper became obsolete, referring specifically to a current technology or media would not add anything to the basic tenets of ethical practice.

What's in the future at APA? For starts, we now have "a new advocacy wing", in APA's Office of Technology Policy & Projects. It's director: David Nickelson, who has pledged to promote the use of Internet-facilitated technology and to work towards moving the monolith association into the 21st century as quickly as possible. There is now research being undertaken to look at "what is actually being done" online, and the new APA Practice Net project is "taking snapshots" and developing an "incredible database" reflecting how psychologists are utilizing the Internet, through ongoing real-time sampling.

Meanwhile, Dr. Nickelson pledged that he will continue his own efforts to "try to integrate telehealth into APA activities" to the extent possible.

As time ran out, the audience had more questions.... Next year in Chicago?

THANK YOU VERY MUCH FOR COMING!


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