Online Psychotherapy:
Technical Difficulties, Formulations and Processes

Michael Fenichel, Ph.D.



There are several technical difficulties inherent in our efforts to transform face to face (f2f) healing relationships into online formats, across Internet-facilitated boundaries and modalities.



Technical Problems

There are several technical difficulties inherent in our efforts to transform face to face (f2f) healing relationships into online formats, across Internet-facilitated boundaries and modalities. This is not to say that an effort to develop such a one-to-one, point-for-point transformation of traditional psychotherapies into equivalent web-based versions is necessarily desirable, even were it conceptually possible. However, it does appear as if the Internet-based community, whoever and wherever that may be, is willing to make a shift in thinking about the various aspects of verbal, interpersonal communication which may be of a healing, "therapeutic" nature.

Clearly, many practitioners who are well-trained and well-experienced in providing "psychotherapy" or counseling of one type or another, are enthusiastically embracing the opportunity which Internet-facilitated communication affords. 1

It is also clear that a large number of people with Internet access continue to utilize the World Wide Web (WWW) in order to seek information about mental health topics, while to a lesser extent (and arguably much more vague in terms of numbers) it appears as if there is a growing "market" for direct online mental health services. With increasing access to an increasingly borderless online community, and fueled by the availability of several for-profit websites which are heavily promoting their own version of "e-therapy" (and for practitioners, easy office management), it seems inevitable that both qualified and wishful mental health professionals will continue to embrace the "easy" way to "do therapy", and a growing number of clients will partake of these services as they increase in accessibility and acceptability. This of course has major implications for both consumers and practitioners of "mental health online".

Some discussions of the nature of online communication, generally (e.g., Fenichel, 2000a, Fenichel, 2000b) have touched upon the positives and negatives of online therapeutic work. Several bodies of work address the nature of interpersonal online dynamics (both individual and group) and outline the unique aspects of online communication such as the tendency towards "dis-inhibition" (e.g., King, 2000, cited in Fenichel, 2000b) as well as the power of "virtual" support groups (Barak, 1999, cited in Fenichel, 2000a). Other discussions focus on the legal and ethical issues inherent in online work. (e.g., Fenichel, 2000c). In a fin-de-siecle interview with a graduate psychology student (Fenichel, 2000d) some additional considerations regarding ethical and safety issues were discussed, which highlighted the importance of professional accountability and contingency planning when determining the appropriateness of engaging in the online treatment of high-risk populations.

Very little empirical evidence is available to shed light on the process , or even the efficacy, of "online therapy", although several researchers (e.g., Fenichel, 1997, Suler, 2000) have touched upon some of the traditional psychoanalytic tenets as they might be applied to online clinical work. Concepts such as "transference", "counter-transference", "acting out", and the "here and now" clearly take on new meaning in Cyberspace. Is a delay in e-mail response a sign of thoughtfulness, or of "resistance"? Is a choice of font style or color clinically significant? How does one explore what seems like a change of tone, or a change in word frequency or message frequency? Are these meaningful? Should they be?

The purpose of this paper is to highlight some of the practical and technical issues which arise in employing traditional "therapy" approaches through the medium of the Internet, as opposed to face-to-face (f2f). Some of the material presented herein comes from presentations made at the American Psychological Association's Year 2000 Convention, while some derives from the study of cognitive neuropsychology and what is known about the processing of language, both in terms of ascribing meaning through experience and in terms of our written language lexicon. But the most fundamental observations and conclusions derive from the ongoing work of the International Society for Mental Health Online (ISMHO), through its Online Case Study Group.
2

Since 1999, this group of geographically and professionally diverse mental health professionals has utilized an Internet-based peer-supervision model to share and explore the dynamics and processes, as well as the technical and technological challenges, of engaging in online clinical work. After an extended period of discussing ethical considerations, the work has come to embrace some meaningful examination of the nature of "therapy" itself, and the various ways in which the Internet can facilitate therapeutic processes and outcomes, whether through support, counseling, therapy, or (for lack of a better term) professionally-moderated self-help. Leaving aside issues of personal preference and style, and the implications for the relative appeal of various communication "channels"--e.g., use of message boards versus list-servs, versus group chat, private chat, or individual e-mail correspondence-- it seems safe to conclude that across our various experiences with mental health services online, it is inarguable that Internet-facilitated mental health services have the potential to make a positive impact on people's quality of life. Our ongoing work continuously affirms the many opportunities for profoundly positive interventions by qualified mental health professionals who have an online presence.

Notwithstanding the potential benefit, we cannot ignore the equally obvious conclusion that there exists substantial opportunity for charlatanism, a lack of appropriate training opportunities (including graduate and continuing education), and a paucity of empirical research on technique, process, and effectiveness, as well.

What follows are some of the more salient issues which emerge in discussing the applicability of traditional "psychotherapy" processes and definitions, in the context of online clinical work. Clearly there are many practitioners who choose not to label such online work as "therapy" (e.g, engaging in "consulting" or "life coaching") while others are more inclined to declare themselves as online therapists, of one type or another. Still others, some with little or no experience doing f2f counseling or therapy, are assuming the mantle of expert online therapist simply by virtue of their own comfort with the Internet.

The following is an attempt to highlight some of the "real" issues which may impact even on "virtual" online treatments.

Not everyone can write fluently or effectively communicate their ideas through typed or written text.

There is evidence to suggest that the literacy skills of many typical adults leave much to be desired. (Some say that the mean level of ability for reading and writing skills in the U.S. is approximately 8th grade.) World-wide, as well as in the U.S., illiteracy is still widespread, which functionally removes the appeal and practicality of text-based communication. While clearly there is beauty to behold in narrative forms of expression--and the use of computers can facilitate both bibliotherapy and text-based relationships of many varieties--it may be unrealistic to expect that reading text on a screen or responding via a keyboard will be a meaningful or practical method for the great many people who, even while motivated by lack of access to other mental health services, are also lacking in written language skills, reading ability, or typing skill.

Psychologists have long been aware of how knowledge is processed, stored, and retrieved, with emotional and referential meaning attached to words. (e.g., see Chomsky, 1957, or any of the work of Freud!) In studying cognitive ability, it is often the case that intellectual skills and daily life accomplishments appear hindered simply by not having had exposure to words or information, because of a lack of reading ability and/or motivation to read and write. Some such clients may be quite adept at oral presentations, but not written, just as in daily practice children are frequently encountered who do a great deal of learning by listening and interacting verbally, but not through reading.
3

An extensive body of literature describes how words affect our thinking in the most profound and yet such basic ways, such as changing the way we adopt the lingo of our professional lives (e.g., DiPietro, 1982). In therapy too, of course, the role of language and word usage is crucial to any discussion of "therapeutic discourse" (e.g., Labov, 1977).

Some people process phonemically but not via the written word.

This is not speculation, but neurological fact. The portions of the brain used to process speech include entirely different sections of the brain than those used to read from written text. It is similarly a different process to speak, spontaneously, than to write. It can be argued, of course, that having the time to compose and edit messages (which is notoriously not very common in responding via e-mail) can result in more thoughtful, focused communication. By the same token, it may reduce the spontaneity or "free association" which is the basis for many of the "non-specific" factors of psychotherapy. What exactly can be made, in such approaches, of the "here and now", or (for the psychoanalytically inclined) of "slips of the mouse"? How might it be a different process of establishing trust via the written word rather than the spoken word?

Aside from the disinhibitory effects of anonymity, and/or the sense of connectedness or belonging (with attendent lessening of self-consciousness or shame), it also appears to be the case that rather than a basis for carefully constructed reaction and response (one major benefit of asynchronous communication) many e-mail users instead react impulsively, without taking the time to formulate a response which may be "in synch" with the original message or the mood or intent of the sender. Lacking such things as tone of voice or body language to provide a sense of nuance, and keep one from becoming too far afield from the original meaning of the communication, there is (as mentioned earlier) additional room for distortion or over-reaction to one or another part of a written text message. This was addressed, for example, at APA's Year 2000 Town Hall Meeting, where APA's executive director, R. Newman described a Harvard study which found that in interpersonal negotiations, e-mail communication was more likely to lead to mis-perception and lack of accommodation than either face-to-face or telephone discussion.

Many will argue that we rely extensively on visual cues....

Many will argue that we rely extensively on visual cues. Others will cite how Freud intentionally blocked them out. But one might argue that finding his office in 19th-Century Vienna and settling down next to him on his couch, even without the visual cues, provided other visceral cues and motivation which would not likely have accomplished the same results via, say, a chat room. While Freud surely did benefit from being able to hear a nervous laugh or sarcastic tone of voice, or seeing a nervous tic, often he utilized the power of the word alone, to evoke mental images and narrative discussions such as in his work with free association and the interpretation of dreams.

Some psychotherapists like to point out that Freud was actually a pioneer in bibliotherapy, and found some patients entirely amenable to analysis via written posts. This is true, in fact, and Freud (despite his adherence to a rigid set of rules at times) was often quiet pragmatic. He was perhaps the father of short-term, symptom-based treatments in addition to performing the longer-term psychanalyses he was known for. In any event, for Freud as for online therapists, the importance of accurately understanding meaning, both surface and deep, remains a central component of being able to provide empathic, accurate interpretation of both words and their underlying significance.

No doubt some patients and therapists who are facile with written expression can benefit from the same opportunities that Freud's written correspondents did, albeit with more opportunities for speed, emoticons, changes of font, and a million other new facets which may all be "grist for the mill" in treatments directed towards deeper self-knowledge.

Granted, there is also much to be said for having direct aural and visual evidence which may suggest signs of nervousness (e.g., from a stammer or cough), nuance of meaning conveyed through tone of voice or facial expression, tremor, smell of alcohol, evidence of something awry with mental or physical status, etc. It is for these reasons that online practitioners are reluctant, or not allowed, to engage in formal diagnosis or certain types of online treatment (e.g., medical) without at least one initial f2f evaluation, and unless there is specific offline contingency planning in place.

Personality and Behavior Issues

Does "Virtual" equal "As-if"?

Question: By anonymizing and time-compressing and "virtualizing" our identities and behaviors online, are we as a Cyber-community establishing an organized as-if, borderline-ish, split-off separate reality where the lines are sharply drawn between Virtual Reality (VR) and Real Life (RL)?

Clearly there are some propononents of "online therapy" who seem to believe that all prior knowledge about psychotherapy and human relationships can be discarded, simply with the premise that "this is a virtual kind of thing", totally new, and therefore immune from the rules and processes of f2f therapies, group dynamics, and shared experience between provider and recipient of mental health services. The danger in "splitting off" online life from the rest of our daily existence may lie, for some, in reinforcement of the notion that what happens online is somehow "not real", or carries different (or no) consequences for what might be termed maladaptive behaviors. Of course, the opportunity for what to many feels like "unconditional positive regard" from one's computer, can also be argued as having a positive impact on self-esteem, assertiveness, or communication skills.

At the same time, within families, homes, and classrooms, one observes with frequency a division of opinion as to how much time and energy is "healthy" versus to what extent time spent online is directly subtracted from time available to spend offline, with family, loved ones, school work, business, or other "RL" (real-life) relationships. Of course, online life is is certainly "real" as well, and as the literature suggests, may play an important, or even crucial role, in the lives of those who may be physically, geographically, or socially isolated, and not otherwise in a position to access information, social support, or mental health services, whether via self-help or professional help services. Some clinical psychologists (e.g., Fenichel, Suler) argue that in a process parallel to therapy and to interpersonal life itself, online activities and relationships are most positive and effective when they are integrated into the whole of one's daily life experiences. Not more or less real, just a different modality of relating to people and ideas.

Cut & Paste Reality

This is an important concept to understand, one which has increasingly become a widespread phenomenon. How often does it happen that someone ends up reading their own words, stripped of the context and inserted with the ease of breathing, into an altogether different message from the original recipient? Worse still, one's words can be recycled as evidence of another's hypocrisy, reneged promises, or worse... He said/she said can become an entirely new art form given the ease with which one can edit out or cut & paste portions of messages, selectively. These altered, contextless snippets may become the basis for misinformation, misrepresentation, provocation to begin a "flame war", or "evidence" of someone's dastardly acts, in the hands of a master of selective attention or virtual reality, whose only reality is what I refer to as "cut and paste reality".

Anyone who has ever seen their own words come back in a post to a committee, personal message, list-serv, or even in a newspaper article, knows the power of selective editing. Context is sometimes everything. But in the hands of someone determined to use little pieces of exact quotes to "prove" another's intent or mis-deed or error, it is quite easy to convince oneself that one is entirely and consistently correct, even putting together a scenario which is said to fit together perfectly, like pieces of a jigsaw puzzle. Sometimes words can be salvation, and sometimes lethal weapons, depending how they are used. In text-based communication, via the Internet, words become enshrined as part of the written record, and remain available for re-reading and re-interpreting, for both positive and negative reasons.

Clinically, online work might on occasion dwell on a particular piece of advice, or comment, which either client or therapist feels has been distorted, or is meaningful. Of course someone with paranoid tendencies will have ample opportunity to cite "evidence" of ill treatment or conspiracy, while some may interpret the words of an online counselor as if tablets sent down from Mt. Sinai. In any event, the ease of playing "word games" has increased exponentially with the ease of establishing "cut & paste reality" where one's world view can be confirmed rather than examined, with the simple click of a mouse.

Computers are Not the Internet
(And Relationships are not Shareware)

"Nobody's Shy in Cyberspace"

So it is said, with a bow towards the well-known phenomenon of Internet-facilitated disinhibition. In fact it may be true that-- once one gets past the mechanics and/or emotional reactions which are part of the experience in sitting down in front of a computer monitor rather than a multi-sensory experience of another person-- it is very easy to forget the computer and become involved in the feeling of being socially connected, whether to a person, small group, or community. (Yes, of course some may appear to become "cathected" to the computer itself, to the point of "addiction", while others crave the immediate social or technological reinforcers which come as instant gratification, on demand. Still others are in fact described as "techno-phobic".)

The Internet, after all, is a web of connections between computers. It has no life of it's own, but the collective information, presence, and interactivity which is contributed, directly and vicariously, by an incredibly large chunk of modern humanity, cannot be minimized. The Internet is enabling both a world community, at the same time it affords opportunities for individual communication which would not have been possible only a short time ago, in the scale of human history. The power of the Internet lies not only in it's infinite ability to provide amusement and information, but also in its potential for facilitating human interactivity, and human relationships. The ease with which immediate gratification can be obtained continues to be the subject of a wide range of study, and of course includes both positive and negative consequences. The reach of the Internet as an interactive medium may bring with it a tendency to speak in hyperpole, so that on one side an orchestra is intent on trumpeting the dangers of the Internet, while on the other side many new Internet users believe that everything one encounters online is terrific and must be "better than perfect".

My own early research (e.g., Fenichel & Dan, 1980) was borne out of a recognition that media hype, and in particular first impressions from newspaper headlines, had a direct effect on the thoughts and emotions of consumers.4 It is with that background that I sometimes wonder if there is not a certain valuation of "selling newspapers" over providing accurate information, which is echoed in many of the new online sites offering Nirvana to clients seeking instant help for mental distress. In fairness, among most online clinicians, both individuals as well as several of the large group practice sites with which I am familiar, there is a recognition that in certain cases--notably with medical or suicide issues-- online treatment is not appropriate, and referrals are made to local providers with licensure and competence (and geographical proximity) to address the presenting problem. But there are also many sites which crop up without any assurance of the providers' qualifications (offline or online), and without much else beyond the equivalent of the big bold headline, proclaiming "Extra! Extra!".

Technology's Possibilities & Limitations

While this paper is focused on the inherent difficulties of applying traditional psychotherapy models to Internet-facilitated communication modalities, clearly the opportunities afforded by technology allow for new and different types of "therapeutic" activities. With this in mind, some (e.g., Grohol, in Fenichel 2000b) have questioned the utility of even trying to make comparisons between offline and online "therapy". Paradoxically, however, the choice of such terms as "e-therapy" does little to discourage such comparison. In my opinion, using descriptions which in fact suggest such one-to-one correspondence, only highlights the difficulties specific to issues of licensure, accreditation, and consumer education.

Notwithstanding my taking issue with some of the terms being applied to what actually takes place between mental health resources and consumers over the Internet, there are of course some compelling arguments that, whatever one calls the online interface between mental health professionals and their clients, there is both a clear need to facilitate access to such services, and a desire of clinicians to provide them.

It is still the case, however, despite the argument being made that a large percentage of people who might benefit from accessing mental health services can now readily celebrate the opportunity to do so, in point of fact the large numbers of people accessing the Internet's mental health resources generally report that they are seeking information, not "therapy". One of the important aspects of sites which provide such information, is that they may lead a viewer to seek professional services once they validate that they are experiencing depression, anxiety, relational problems or other common difficulties. Some sites, of course, do offer services directly (through their own counselors/therapists/coaches/advisors) while others offer referrals to community-based practitioners local to the client. Still others provide self-help resources or links to online and offline support groups. Finally, and sadly, some sites offer therapy or counseling without even stating the identity or qualifications of the provider.

(For a discussion of some of the ethical and legal issues involved with online therapy, please see http://www.fenichel.com/QAT.shtml#OT)



There are also technical possibilities of uniquely positive nature as well, including the roles of anonymity, portability, and accessibility.

Language, Lexicon & Online Communication


As described in my paper on Language and the Way We Think (Fenichel, 1987), and extrapolated here from research into the language of doctor-patient communication, "the roles of both patient and physician are wrought with interpersonal expectations and demands. Often these are not only of profound importance for self-esteem (i.e., feeling one is in control of a serious situation), but may in fact entail life and death consequences."

And online? Certainly there is no less of a calling for shared language between provider and recipient of language-based therapies. Since that paper was originally written, two decades ago, there has been a movement towards the de-mystification of everything from the law to pharmaceutical effects, and research into health psychology has consistently demonstrated the value of having informed understanding of a course of treatment. For example, knowing what pain and benefits are involved in surgical procedures, along with information about time frame and recovery outlook, tends to reduce experienced discomfort and shorten recovery time. By extension, it seems only reasonable to assume that having an accurate understanding about the task of online "therapy" might also help enlist motivation and resolve on the part of someone who is seeking an active intervention. On the other hand, if someone is in search of friendship, support, or information, this is easy to obtain online as well. But is it therapy? :-)

Our worlds are shaped by our percepts and experiences5, and stored both visually and linguistically. We have a stored lexicon for both, and different processing channels, some which are unique and some which overlap. We do not yet have a shared lexicon for discussing "online therapy". Can we develop the requisite "transference neuroses" to enable an interpretive psychoanalysis? Can this be done where "free association" is disrupted by the sounds of "You've Got Mail!" and the warble of a cell-phone? Maybe, maybe not.

There is growing anecdotal evidence that use of cognitive assignments and online treatment have been effective at addressing social anxiety. (But does it generalize to offline life, from online?) Great success stories abound about improved relationships, self-awareness, and the value of support in making it through a stressful time, or crisis. Married couples have reported successes, while group dynamics in chat rooms and message boards are said to have infinitely improved people's awareness and social skills. Self-help sites are blossoming everywhere, and even the youngest children turn to the Internet for information, as their parents seek everything from shopping bargains to referrals for medical conditions.

Certainly there is a great deal of therapeutic benefit which is being derived online, in many ways, by many definitions. Clearly there needs to be continued study of both the process and outcome of various mental health services as they now exist, and training of mental health professionals to better understand both the potential benefits and potential risks of engaging clients online. At the same time, peer-supervision and case study approaches are important tools for improving our ability to develop and share techniques which prove successful, with the professional community. At the same time, consumer advocates rightfully insist that only those who are indeed qualified to provide psychotherapy are the ones who are marketing and providing those services online.

Bibliography

Chomsky, N., Syntactic Structures, The Hague, Paris: Mouton, 1957.

DiPietro, R. (ed.), Linguistics and the Professions: Proceedings of the Second Annual Delaware Symposium on Language Studies, Norwood N.J.: Ablex, 1982.

Fenichel, M., (1987) Language and the Way We Think, Presented as a paper originally in 1987. Revised online version available online and published continuously since 1996, at http://www.fenichel.com/language.shtml

Fenichel, M., (1997) Internet Addiction, Online at http://www.fenichel.com/addiction.shtml

Fenichel, M., (2000a) Online Therapy, Online at http://www.fenichel.com/OnlineTherapy.shtml

Fenichel, M., (2000b) Town Hall Meeting: APA 2000, Online at http://www.fenichel.com/TownHall.shtml

Fenichel, M., (2000c) Current Topics in Psychology, Online at http://www.fenichel.com/Current.shtml since 1996

Fenichel, M., (2000d) Questions and Answers for Psychology Students: The Ethics of Online Therapy, 2000.

Fenichel, M. and Dan, P. (1980) Heads from Post and Times on Three-Mile Island, Journalism Quarterly, Vol.77, No.2, (Summer 1980), pp.338-339, 368.

Labov, W. Therapeutic Discourse: Psychotherapy as Conversation, NY.: Academic Press, 1977.

Suler, J. The Psychology of Cyberspace, accessed online (2000) at http://www.rider.edu/users/suler/psycyber/psycyber.html

Footnotes

1 Another entire dimension of "technical problem" emerges on the practitioner side, when both legal and ethical standards for licensed professionals are examined. For example, in the U.S., psychologists and psychiatrists are licensed to practice in a particular state. In the case of California, psychologists must be licensed to provide "psychological services" within the State of California--including via Internet-- to residents of that state. [For more information on some of the legal and ethical issues binding psychologists, please see http://www.fenichel.com/QAT.shtml#OT] On the consumer side, while there are some safeguards which states offer in terms of regulating licensed mental health professionals, consumers may be misled by online providers who do not provide sufficient information to make a determination of qualifications or competency. The axiom caveat emptor (buyer beware) is still considered to be a Golden Rule online, just as offline.

2 See International Society For Mental Health Online, http://www.ismho.org/casestudy/

3 The topic of child psychotherapy presents an entirely new dimension of concern, with regard to online work, in terms of both legal and ethical issues, quite obviously, and additionally in terms of practical issues such as confirming identity, as well as the entirely un-defined nature of how children might relate to guided online tasks in interaction with a "therapist".

4 Fenichel and Dan (1980) found that scream headlines sold papers but provided little information communication through language. Some words and buzzwords appear more visceral than factual in design, and choices are often made as to whether to relate on an intellectual/factual basis, or an urgent and emotional basis.

5 For a dialog on the topic of how each of us develops meaning from experience, see
Ego: The Cauldron of Personality, Fenichel (1997).




Psychotherapy

(from FUNK & WAGNALLS Standard Desk Dictionary)

psychotherapy -
The treatment of nervous and mental disorders, by psychological methods, as hypnosis, re-education, psychoanalysis, etc.


(from WEBSTER'S Unabridged Dictionary)

n., the application of various forms of mental treatment, as hypnosis, suggestion, psychoanalysis, etc., to nervous and mental disorders.




[Psi] Current Topics in Psychology | APA 2000 Convention Reports

APA Convention Articles:
2000 : Asynchronously Live: 2000 Highlights: Beck-Ellis Dialogue | Town Hall Meeting
2001 : Behavioral Telehealth | E-biz of Mental Health | 2001: A Cyberspace Odyssey
2002 : CyberSex | Beck & Ellis 2002 | Behavior Therapy | CyberPsychology | E-Ethics
2003 : Full Text | Aaron Beck 2003 | Quality of Online Health Info | Sternberg's Vision
2005 : 2005: Pioneers of Behavior Therapy | Distinguished Elders | Online Clinical Work
2006 : Asynchronously Live From New Orleans : Further Conversation with Aaron T. Beck
2007 : Humanizing an Inhumane World | Albert Bandura | Beck 2007 | Evil, Hate, & Horror
2008 : Grand Theft Childhood | Malcolm Gladwell | Beck 2008 | The Mind & Brain of Voters
2009 : Internet: Pathway for Networking, Connecting & Addiction | Virtual Psychology & Therapy
2010 : Online Support Groups & Apps | Evidence & Ethics | Resilience | Hayes: What the World Needs





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