Dr. Dror Green
The History of Online Psychotherapy
(This is the first part of my PhD research on online psychotherapy, supervised by Prof. Robert, M. Young, submitted to Regent's College, City University, London)
The therapeutic characteristics of online relationships
The Internet is not only a technical device that provides a new kind of communication, but also a huge generator of psychotherapeutic processes. Online communication is based on 'virtual communities', which most Internet users have experienced (Horrigan, 2001, Rheingold, 1994, Wallace, 1999). 'Despite the ephemeral and fragile nature of so many forums on the Internet, there is evidence that a very strong sense of 'groupness' does emerge regularly' (Wallace, 1999: 56).
Heidi Figueroa-Sarriera points at the new kind of identity and personality that manifests itself in virtual communication. This phenomenon contradicts the four statements that define personal identity, according to Ignacio Martin-Baro (1985): that identity exists in reference to a world, that it asserts itself in the interpersonal relationship, that it is relatively stable and that it is a product of society and of an individual's actions. In virtual communities identity is a mask or a means for performance:
The online environment provides new experiences, which involve mental implications and have psychotherapeutic effects:
Many therapists who resist the idea of online psychotherapy adhere to the claim that therapeutic relationships cannot be comprehensive and deep without the clues of non-verbal cues. This claim ignores the rapid expansion of the Internet culture, which is based on textual relationships. Even in face-to-face traditional psychotherapy one cannot understand clients' language and associations without being introduced to the Internet. The experiencing of online communication by hundreds of millions of people makes its mark on psychotherapists as well as on their clients. Virtual reality is part of everyday life, and no one can ignore this phenomenon:
In the new era of online communication, people develop new skills for human interaction, introspection, self-actualisation and improvement of their 'multiple-personality' system. These new skills are affecting the field of psychotherapy in some meaningful ways.
These new characteristics of online communications affect clients and psychotherapists, illuminating certain similarities between psychotherapeutic procedures and online situations.
Similar understandings were concluded from experiments in virtual support groups:
Online relationships are influenced by psychotherapeutic procedures while affecting and changing the nature of psychotherapy. In online therapy the term 'talking cure' is changing into 'corresponding cure' and this process amplifies the significance of 'text relationships' in psychotherapy.
The psychotherapeutic characteristics of online communication and its influences on clients and psychotherapists are demonstrated in the short history of online psychotherapy, which developed from telephone therapy to forum therapy.
Therapeutic correspondence in narrative psychotherapy
Online psychotherapy is naturally based on textual dialogue, which is different by definition from the traditional face-to-face interaction or even from vocal telephone counselling. But textual dialogues, particularly written therapeutic messages, were not invented during the Internet era. It was preceded by the growing field of the Narrative approach in the last two decades. White and Epston (1990), who were the pioneers of the narrative approach, were influenced by Michel Foucault, who 'asserts that those perspectives that become dominant culture narratives have to be challenged at every level and every opportunity, because their function is, in part, to minimize or eliminate alternative knowledge-positions and alternative narratives' (Corey, 1996: 409). David Epston has developed a special use for letters in his style of narrative therapy, or 'storied therapy' as defined by him:
This formulation of 'storied therapy' can be easily replaced by online psychotherapy, in which textual dialogues 'become the shared property' (ibid.) of both therapist and client, and 'can be substituted for case records' (ibid.). Epston integrates correspondence into the therapeutic process in many creative ways: letters of invitation, redundancy letters, letters of prediction, counter-referral letters, letters of reference, letters for special occasions and brief letters (White & Epston, 1990). These applications of correspondence can be observed and researched in online psychotherapy as well.
In narrative psychotherapy, clients are expected to take responsibility for their stories, or to be the authors of their stories. Since ordinary people might be apprehensive about writing stories or exposing their literary skills, writing letters can be a convenient way of freely expressing their narratives.
Narrative psychotherapy focuses on the therapeutic aspects of the autobiographic process.
As a narrative psychotherapist I have found online psychotherapy the ideal setting for the therapeutic dialogue. Using written messages as the main instrument for creating therapeutic relationships (in addition to occasional online telephone) seemed a natural move; I am still wondering why online therapy has not become the main stage for narrative psychotherapy.
Online psychotherapy is associated with personal computers and is frequently misunderstood and confused with the concept of psychotherapeutic computer programmes.
There are no similarities between Eliza and online psychotherapy, although both are based on computer communication. 'But what makes this computer program different, however, is that most of the initial ELIZA users thought they were chatting with another person via the computer screen' (Grohol, 2004: 52). Even today the resistance to online psychotherapy is still based on the assumption that online psychotherapy is 'mechanical', 'cold' or 'inhuman', arguments that could be attributed to the original 'Eliza'.
While online psychotherapy has made significant progress since 1995, the development of psychotherapeutic software was limited to self-help programmes for cognitive behavioural techniques like desensitisation, relaxation or problem-solving interventions. Some psychotherapeutic software programmes are presented on the net, pretending to provide online psychotherapy, whereas many other sites offer self-help programmes for mental disorders.
Online psychotherapy was influenced and strengthened by the experiences of computerised psychotherapy, which nevertheless remained far behind. Although these two innovative kinds of psychotherapy follow parallel paths, it is most probable that further developments in computerised psychotherapy will change the situation, integrating it into the developing field of online psychotherapy.
Although the first telephone service for psychological interventions started in the USA in the early 1900s, such services only became popular in the second half of the twentieth century. On November 2nd, 1953, the first call was made in the UK to '999 for the suicidal', and this date is still the official birth date of the 'Samaritans'.
Since the 1950s, telephone helplines have become common and non-profit organisations offer telephone help to children, abused women, breast cancer patients, etc. (the Samaritans, Shelterline, ChildLine & CancerBACUP).
The long experience of telephone helplines has led to professional individual telephone psychotherapy and counselling. Pete Sanders (Sanders, 1996: 4) suggests some types of groups that need this kind of therapy:
This list also perfectly describes people who need online therapy, and for the same reasons.
Telephone psychotherapy, as a precedent to online psychotherapy, is a reliable practice today and as such serves to promote online therapy. 'Telephone therapy has been shown to be a cost-effective, clinically-useful, ethical intervention modality in the research literature' (Grohol, 1997). The characteristics of telephone counselling and its benefits are similar to those of online counselling.
In 1977, I volunteered for the Israeli helpline for emotional support, where I listened to anonymous callers for four hours a week for five years,. During these years I documented all my dialogues in an attempt to define the therapeutic characteristics of these encounters. My main finding was that due to the extreme phenomenon of transference (and ground rules) a telephone relationship and trust is created in a very short time. The limited setting and the focus on time restrictions accelerate the therapeutic process and shape the goals and expectations of the client.
My experience as a telephone helpline volunteer and supervisor prepared me naturally for online psychotherapy. On the one hand, my skills as a telephone counsellor served me well for online therapy, and on the other hand, I still integrate Internet telephone into my online therapy practice. Telephone counselling, therefore, was my natural training and preparation for online psychotherapy. While searching the net for online therapy services, I discovered similar processes. Many sites that offer online therapy enable their clients to choose between face-to-face therapy, telephone therapy and e-mail therapy. The adjacency of telephone and online psychotherapy is tuning and shaping the future of online psychotherapy, as can be found in the APA code of ethics.
Telephone counselling and psychotherapy preceded online therapy and contributed to its development. The fast evolution of online technologies integrates telephone and video communication with online written communications, and it will not be surprising if telephone psychotherapy merges with online therapy in the near future.
Videoconferencing in psychiatry and psychotherapy
The terms 'telehealth' and 'telepsychiatry' have a forty-year history, and the use of videoconferencing in psychiatry has been well researched and documented:
The Nebraska Psychiatric Institute used videoconferencing for medical consultation, training and education in 1964 (Simpson, 2003: 109). Wittson and Benschoter (1972) published the first study about the use of videoconferencing for group psychotherapy, which was performed at the same place. Most research of the use of videoconferencing for psychotherapy took place in the USA, Australia and Scotland, testing a variety of therapeutic methods: psychoanalysis, cognitive-behavioural therapy, family therapy and video-hypnosis (Simpson, 2003: 110).
Videoconferencing is the most similar technological-setting to face-to-face psychotherapy, since except for smell, it captures all physical gestures. Nevertheless, due to technical complications and high cost, videoconferencing was not practical for individual psychotherapy in the past. The fast development of the Internet, which makes online video-chat available to all surfers, has changed the whole situation. 'The integration of classic telemedicine and telehealth technologies with the Internet was the next logical step. Now that technology is ready for the merger, its sudden growth is staggering' (Maheu, 2000).
Online self-help groups, support groups and group psychotherapy
The main difference between the Internet and previous means of communication (mail, telephone, radio, television, etc.) is that it enables accessible and simple group communication, which serves as a platform for the creation of online communities.
From its early days the Internet functioned as a support-group for many surfers in various ways (Colon & Friedman, 2003: 60).
4. Mailing lists (listservs) are different from chat rooms, in that they constitute asynchronous correspondence and can be 'moderated' (the group 'moderator' can read the message and aprove its content before it is published).
5. The 'forum' has been the main platform for online groups since 1996, and several hundred thousand forums function as self-help groups. The forum integrates the characteristics of a chat room and a BBS, and it can be synchronous or asynchronous. Threads in a forum are either flat (posts are listed in chronological order) or threaded (each post is made in reply to a parent post).
Online groups can be 'open' to all surfers, who can be anonymous and choose a pseudonym, or secured by password to a group of recognised members. Some of them are dedicated to a special topic, which is shared by all members (cancer, depression, etc.), and some reflect the characteristics of the members (students, single mothers, etc.).
Although some researchers claim that it is still difficult to conduct qualitative research, concerning self-help groups (Eysenbach, Powell, Englesakis, Rizo and Stern, 2004), most research studies identify the phenomena of online self-help groups as a substitute for professional help.
Online support groups were developed at the end of the 1990s, facilitated by trained group leaders. They have usually been sponsored by official organisations. Yvette Colón (Bellafoire, Colón & Rosenberg: 2004) facilitated an experimental group in 1993 for people who committed to participating in a three-month online psychotherapeutic experiment for eight participants. Participant feedback indicated that most felt the groups had helped (ibid., 198). Colón continued with support groups for cancer patients and caregivers, on bulletin boards and listserv.
Donna Bellafiore (ibid.) started a self-help group in 1998 for people dealing with infidelity. It was an 'open' bulletin board, operating 24-hour a day, seven days a week. In a short time there were more than 900 participants daily. In 2001, due to disruptive and destructive behaviour of some participants, Bellafoire changed it to a traditional membership group.
The growth in online groups, most of which function as self-help groups, makes a significant change in the international culture of the third millennium. This change cannot escape the psychotherapeutic community, signs of which can be found in the slow adaptation of psychotherapists to the Internet era.
Experiencing online support groups and online group psychotherapy, therapists started to discover the new setting. Although online groups are different from face-to-face groups, as it is difficult to identify the presence of participants who are not active, therapists could examine the differences and the similarities of the two modes:
These new experiences with work groups prepared psychotherapists for the previously threatening idea of online psychotherapy and served as preliminary training for future online psychotherapists.
Online free advice-giving
The Internet is the main source of information for the 'global village' and it naturally enables clients to learn more about psychotherapy, mental illnesses, their own feelings and their therapists.
John Grohol, the author of The Insider's Guide to Mental Health Resources (Grohol, 1999), wrote the first professional guide to the virtual world. A graduate student in psychology, he formulated an intimate relationship with the net in 1991 by answering mental health questions when participating in a Usenet newsgroup. He created the first online index of mental health support groups and, in 1995, he established his own site, Psych Central, and started a free weekly chat (psychcentral.com/chats.htm) that continues to this day.
In the 1990's the Internet moved into the commercial era and, naturally enough, psychotherapists, like many others, would try to reap financial benefits from their efforts in this area.
The first fee-based services were similar in style to online advice-giving ('mental health advice'). They offered answers to all types of questions for a small fee. Dr. Leonard Holmes was the first to offer 'Shareware Psychological Consultation', meaning that he answered questions by e-mail on a 'pay if it helps' basis. The service was based on a single interaction and did not establish a 'therapeutic' relationship. Two other services were launched at the same time, namely 'Help Net' and 'Shrink Link', which also offered fee-based mental health advice.
The evolution of e-clinics enabled many therapists, having no knowledge of online technologies, to join the new venture for a considerable monthly fee. On the other hand, clients could visit these sites and choose the appropriate therapist from a list of online therapists. Some e-clinics, like 'HelpHorizons.com' (www.helphorizons.com) and 'Find-A-Therapist' (www.e-therapyelper.com) are still operative, while other e-clinics, like LifeHelper.com and etherapy.com could not afford the huge investments involved and closed down.
The increase in online therapy sites at the end of the 1990s, was followed by a decrease at the end of the dot.com. period.
My experience has taught me that the slow progress of online psychotherapy is the consequence of most conservative psychotherapists’ ingrained resistance to it. It is not coincidental that ISMHO includes consumers and therapists. Clients play an indispensable role in the development of online psychotherapy. Clients' satisfaction is the main fuel for the progress of this new field. Martha Ainsworth (2001), in her pioneering site (ABC of Internet Therapy: Metanoia.org), offered advice for e-patients and e-therapists.
The Methods of Online Psychotherapy
Since 2005, the Internet has made it possible to imitate face-to-face psychotherapy, moreover, there are no longer any technical limitations regarding therapists' and clients' communication through videoconference.
The natural and basic environment of the Internet is textual (e-mail and chat room) and it is reasonable to assume that online psychotherapy will also be based on text. It could have been changed and extended to other ways of communication in accordance with the technical development of the Internet, but it has definitely ignored these possibilities and stuck to the written setting. I assume that the textual option was chosen for its special qualities, which were exposed accidentally due to the nature and history of the Internet. I will attempt to explore this phenomenon later.
This form of online psychotherapy imitates the linear dialogue and the time limitations of face-to-face psychotherapy. It is based on a synchronised dialogue between therapist and client, e.g., for fifty minutes once a week, at a fixed time. Chat software programmes are based on a split screen. On the upper screen both therapist and client can read the last sentences of their dialogue and on the lower part each of them can type his next sentence. Clicking the 'enter' key sends the text to the upper screen, but participants cannot send more than one paragraph at a time. There is another option for chat programmes whereby both parties can see everything they type as it is type it, including mistakes and corrections. This architecture influences the nature and tempo of the dialogue, which is based on a swift and segmented process. Due to the nature of chat room therapy, the therapeutic process always focuses on the last sentence, or the last minute (the 'here and now') and demands concentration, active participation and an immediate response, all of which make the option of 'evenly-hovering attention' (Freud, 1912: 324) impossible. It could be like the following fictional dialogue:
While this sort of dialogue is based on support and empathy, referring to the 'here and now' situation, there is no room for silence, and it is difficult to 'bracket' (Spinelly, 1989: 17) spontaneous feelings and just 'be with' the client. This condensed situation can prevent listening, reflecting, containing and interpreting. The chat programme does not create a feeling of a 'secure frame' since it is impersonal, with no special characteristics that can resemble intimacy, privacy, exclusivity and confidentiality. Thus, it could be compared to a therapeutic session taking place in a coffee shop.
2. E-mail therapy.
E-mail psychotherapy is the main setting for online psychotherapy. It consists of a written correspondence between client and therapist; in fact, there is no principal difference between e-mail therapy and the use of therapeutic letters in narrative therapy. E-mails have some advantages. First, sending an e-mail is cost free. Second, they are received almost immediately. This means that a therapist can promise to send an e-mail to his client at an exact time. Third, e-mail correspondence can be confidential, so that no one knows about or sees the correspondence. A copy of each e-mail is kept in the sender's computer and the whole correspondence is documented on both parties' computers.
There is no shared setting for e-mail psychotherapy. Each participant uses his own e-mail software, which has a particular design and form. While the therapist might use Outlook Express,
the client could reply with Hotmail.
This is a parallel communication in which there are two sets of therapeutic environments. Each participant saves the therapeutic message on his private computer, under his own control. At the same time, each participant knows that the other keeps the same information in another computer that is less secure as far as he is concerned.
E-mail psychotherapy differs from face-to-face or chat psychotherapy in that it creates a new type of communication. It can be compared to two people sharing a notebook in which they write their personal diaries at different times. Although they never meet each other, they share an intimate aspect of their lives, while maintining their privacy and autonomy.
My experience has taught me that e-mail therapy has many advantages when it follows face-to-face therapy. When therapy is terminated abruptly due to unexpected circumstances, e-mail therapy is a practical tool for concluding the therapeutic process and preparing for separation. In other cases, e-mail psychotherapy creates a secure framework for people who need to preserve their anonymity. In most cases these are professionals who cannot contact other therapists due to parallel relations in the intimate professional milieu of a small country. E-mail psychotherapy is characterised by the special qualities of online psychotherapy. Written narratives create a high degree of self-awareness. The text, as objective data, has a new status in the psychotherapeutic process. The equal access of both therapist and client to past narratives, which are kept on their computers, create a new kind of therapeutic relationship.
This option serves online support groups or online group psychotherapy and preceded individual online therapy, as described above. Discussion groups, or forums, integrate the qualities of chat room and e-mail therapy. They provide an organised space in which information can be stored and easily retrieved. Participants can ask a question or send a message to other participants, while all messages are documented in the same order. Some forums are linear, i.e., all messages are presented successively one after the other in chronological order. More sophisticated forums have the architecture of a catalogue tree. Each member can send a new message, which is then presented as a new branch of the catalogue tree and each participant can reply to this message in a hierarchical order. Each message indicates the time it was sent and participants can reply to new and old messages whenever they decide to do so.
Discussion groups are located on a remote computer on the web, which is not dependent on the therapist's or participants' computers. This special architecture enables both synchronous and asynchronous communication. There can be scheduled sessions, when participants and therapist communicate in real-time, while participants can reply to messages or read previous messages at any time.
These three types of online psychotherapy are text-based. They all represent a psychotherapeutic use of common Internet means of communication, which are not adapted to the special needs of the therapeutic encounter. Later I will present the 'New Forum', which I developed as a virtual clinic and adapted to the demands of a therapeutic environment.
The adaptation of traditional psychotherapy to the new era of the Internet is not self-evident. The technological aspects of the Internet (and computers in general) evoke a wide range of resistance from both therapists and clients.
Body Language and the Therapeutic Relationship
The main argument against online psychotherapy is the lack of eye contact and body language. Many clients and therapists believe that non-verbal communication, and its interpretation by the therapist, plays a central role in the therapeutic situation.
This is true. There is no non-verbal communication in online psychotherapy, as it is based solely on textual dialogue. However, some online therapy experts believe that this is not a disadvantage:
Body language is part of any sort of human relationship, and it is not unique to the psychotherapeutic relationship. The conditioning of body language and psychotherapy is natural and self evident, but it has nothing to do with the therapeutic situation, which is different from any other human interaction. Psychotherapeutic relationships are synthetic and artificial, and serve as a laboratory for investigation. Eye contact and body language can be investigated as part of this artificial intercourse, but they are not, in themselves, the goal of the psychotherapeutic process.
Actually, Freud could not eliminate all aspects of physical interaction, such as space, smell and voice intonation. Freud ignored these aspects of physical interaction, and one may guess that he would be interested in neutralising them in order to create the ultimate neutrality. By that he could explore the role of transference in a neutral scientific environment.
Since this ideal situation was impossible in Freud's time, it was forgotten, and pure transference was never achieved or explored. The new online setting is the first opportunity to research and explore Freud's assumptions concerning transference and neutrality:
Conservative psychotherapists who are not familiar with online therapy, like Gaby Shefler, the Chair of the Ethical Committee of the Association of Israeli Psychologists, sometimes resist the idea of online psychotherapy with the circular claim that 'therapeutic theories are based on a face-to-face encounter' (Psycho-Actualia, 2005: 41).
This new kind of 'body language' expresses itself in the 'body' message, in Suler's words, which reflects the personality of the writer 'between the lines'.
I can add to this that text-based psychotherapy is not equal to a textual presentation of a recorded face-to-face therapeutic session, which isolates the words from their physical context. Online text represents a new type of therapeutic message, which may be associated with the virtual setting by hypertextual links. Hypertext constitutes a rich embedding of associations and hidden unconscious messages, which reflect the multilevel structure of the human mind.
The difference between the technical environment of online psychotherapy and face-to-face traditional therapy raises certain ethical dilemmas concerning the practical and theoretical aspects of online therapy. Some of these dilemmas have found their way into a new code of ethics, which has been formulated for online therapy by the International Society for Mental Health Online (ISMHO, 2000), as well as leading to changes in the ethical codes of therapists' organisations (ACA: 1999, HONcode: 1997, AMIA: 1997, APA: 1997, nbcc: 2001, ETHICS code: 1999).
Actually, there is no way of guaranteeing professional competency for online psychotherapy, since there is not enough experience in the field, and there are no comprehensive training programmes that can provide such competency. This means that online psychotherapists have to inform their clients about this gap in online training and give them detailed information, concerning their own experience and training in this new field.
To be competent in online psychotherapy, practitioners have to take responsibility for their own professional training. They have to be aware of their writing capacities and their mastery of computers and Internet technology. Online therapists have to be flexible and open-minded, since they cannot adapt their face-to-face approach to online practice without effecting certain changes.
Confidentiality plays a central role in face-to face psychotherapy, and online psychotherapy might arouse considerable apprehension in this area. The technical devices and information transportation of online communications amplify these feelings, making it difficult to create a trusting relationship between therapists and clients.
The question of confidentiality is connected to clients' understanding and experience of the new media. I have found that experienced Internet surfers have no difficulties with confidentiality in online psychotherapy, while face-to-face 'fresh' clients need some time to create trust.
Actually, there is nothing therapists or clients can do against someone who intentionally plans to steal their secrets. This can be done by breaking into the therapist's clinic or his house, as well as hacking into his computer. Online therapists invest more energy than face-to-face therapists in protecting their clients' confidentiality. This is accomplished by encrypting client' e-mails or by using secure web-based messaging systems. Online individual therapy is more protected than public mental health institutions, where sensitive information about patients is available to other therapists and administrators.
Online psychotherapy is not beneficial to clients who cannot type or operate a computer, clients with pathological symptoms or clients in crisis, clients with medical problems, famous clients, clients with no writing and reading skills and clients who are still engaged in face-to-face psychotherapy.
While in some countries psychotherapists do not need a licence to practise, there are regulations for practising psychotherapy in other countries and American therapists 'practice under a government-issue license that authorizes them to practice in a specific state' (ibid.). This means that I can live in Israel and treat a client in Japan, but an American psychologist from Virginia cannot serve clients in Ohio.
In order to avoid lawsuits and professional discomfort many therapists do not define their practice as psychotherapy or counselling and abstain from any commitment of this kind. Instead, they formulate a cautious contract that makes the client partially responsible for the process.
Other online therapists differentiate between psychotherapy and counselling by claiming that psychotherapy is more directive than counselling.
Some online therapists do not hesitate to offer "therapy": 'While in internet therapy, or cyber therapy, you will be chatting live to a professional therapist. You will be receiving this service in the privacy of your own home' (The Cyber Shrink), but they also add some restrictions:
The option of preserving clients' anonymity enables clients who avoid psychotherapy due to the stigma to start psychotherapy. Although anonymity is one of the characteristics of online communication, it has some disadvantages in online psychotherapy. Clients' anonymity can postpone the creation of trust and weaken therapeutic relationships.
Therapists' anonymity can enhance the phenomenon of transference, in psychoanalytic terms, or guard clients from frame deviations by practitioners, in communicative psychotherapy terms:
In online psychotherapy clients' anonymity is of similar value. This anonymity derives from the lack of the physical dimension, which focuses therapists' attention on clients' narratives. In a way, this anonymity may be associated with the Freudian couch by helping online therapists to bracket their personal beliefs, judgements and prejudices.
Online Psychotherapy and Scientific Research
The psychotherapeutic process is difficult to research since it is based on subjective impressions of therapists (case studies) and clients (questionnaires). It is impossible to collect data concerning inner mental processes, and the therapeutic procedure, which includes physical setting and body language, is too complicated to explore.
Although online psychotherapy is the youngest branch of psychotherapy, celebrating its tenth birthday (10), it is rooted in the long history of telemedicine, which started half a century ago. Telephone help-lines and videoconferencing systems paved the path to online psychotherapy and prepared the ground for assimilating accumulated experience into the psychotherapeutic field.
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