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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) 

It is conventionally assumed that professional fee-based online individual psychotherapy started in 1995 (Ainsworth, 2002: 205, Grohol, 2004: 60, Anthony, 2003: 25), but one cannot ignore the context in which this process is still developing, or the therapeutic characteristics of the Internet.
Online individual psychotherapy is a natural development of the rapid increase in online support groups since the 1970s (Grohol, 2004: 54) and free advice-giving by professional therapists in the 1980s (Ainsworth, 2002: 205). It is also an evolutionary process, derived from telephone psychotherapy (Rosenfield, 2003: 93), telephone helplines and psychiatric videoconferencing (Simpson, 2003: 109, Gibson, Morley & Romeo-Wolff, 2002: 69).
Earlier influences on the development of online psychotherapy can be found in computer programmes, which replaced human psychotherapists in the 1960s (Cavanagh, Zack, Shapiro & Wright, 2003: 143), and in the practice of therapeutic correspondence, in the growing field of narrative psychotherapy (White & Epston, 1990, Freedman & Combes, 1996, Monk, Winslade, Crocket & Epston, 1997, Omer & Alon, 1997, Rainer, 1997, Roberts, 1994, Parry & Doan, 1994).
Online individual psychotherapy, therefore, is rooted in the technical and theoretical developments of psychotherapy in the second half of the twentieth century, and can be grasped as a natural outcome of these processes.

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).
In a way, millions of people do 'group therapy' on the Internet. 'Freud might well have said, were he here to take this all in: "It's very easy to find websites, groups, and online activities and objects to which cathexis can be bound (and through which libido can be sublimated), and the Internet allows for a great deal of ease in free-association, transference, and projection"' (Fenichel, 2004: 6). Virtual communities enable their participants to train in social skills and discover their mental capacities. 'It is apparent that for many people "cyberspace" offers an alternative, of "virtual" reality that can be dissociated from other aspects of daily life' (ibid.: 7).
The interpersonal interactions in virtual communities provoke mental processes that can be therapeutic or destructive. The unique environment of virtual communities, which is based on written communication, anonymity and role play, exaggerates group dynamics and personal changes. In Sherry Turkle's words, 'When we step through the screen into virtual communities, we reconstruct our identities on the other side of the looking glass' (Turkle, 1997: 177). Patricia Wallace explains the existence of our 'online persona' (Wallace, 1999: 14) by claiming that virtual setting is different from 'real life' setting, changing our impression formation and impression management. 'These processes unfold differently in cyberspace because the cues you use to form impressions, and the tools you use to create your own, are quite different than they are in real life' (ibid: 2).
From the early days of online communication, it served as a huge playground. The first online communities gathered in MUDs (Multi-User Dungeons), some kinds of software (like Muse, Moo or Mush) that created virtual spaces where surfers could build their own world, converse with other surfers and navigate between similar virtual worlds. Actually, MUDs supplied the ultimate environment for personal reconstruction.

MUDs are dramatic examples of how computer-mediated communication can serve as a place for the construction and reconstruction of identity… When people can play at having different genders and different lives, it isn't surprising that for some this play has become as real as what we conventionally think of as their lives, although for them this is no longer a valid distinction.
(Turkle, 1997: 14)

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:

In contrast, the performative model of the self that underlies the notion of symbolic interaction assumes that the identity is a construct that emerges in direct relation to particular circumstances. Identity is seen as "the face" that the subject shows by his or her performance within certain contexts. This leads us to a notion of identity as a strictly circumstantial and contingent construct.
(Figueroa-Sarriera, 1999: 136)

The online environment provides new experiences, which involve mental implications and have psychotherapeutic effects:

Clearly, a new psychology is emerging. Patterns of interaction are evolving from concepts like netiquette and list protocols. Aggressive, uninhibited behavior is increasing from the anonymity and the absence of social constraints in cyberspace. The self is being split in multiple directions, adopting distinctive identities and roles. Sex is being redefined as an experience of shared fantasies and virtual caresses. The simulation of reality online has become its own, unique process. And anything can happen.
(Fink, 1999: xx)

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 a therapy session a few years ago, a patient asked me what my opinion was of Internet relationships. My first reaction was that I had no opinion, and even less of an idea of why the patient had asked the question. Invoking the time-honored, and in this case somewhat uninspired, therapeutic strategy of answering with a question, I asked my patient if he thought I ought to have an opinion. With an incredulous sigh and a brow furrowed with disapproval, the patient responded, 'Of course you should have an opinion. Do you live in the same world I do?'
(Civin, 2000: xi)

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.

  1. Clients are exposed to a wide range of information concerning psychotherapeutic theories and technique. They become more critical and sceptical, and their resistance is 'rooted' in their new online capacities.
  2. Boundaries between therapists and clients are more fluid since clients know more about their therapists and can trace their private and professional activities on the net.
  3. Therapeutic relationships are less exclusive since clients can be supervised in relation to their therapy by other professional therapists or by other clients in online support forums and in professional 'psychological' forums.
  4. Clients can violate a therapist's privacy by exposing her through the net.
  5. Therapeutic processes can be accelerated by clients' experiences in online role-play.
  6. Some characteristics of online relationships are similar to psychotherapeutic relationships, since anonymity, neutrality and support sometimes qualify the online setting, as in some ground rules of psychotherapy. This means that online surfers are prepared for online psychotherapy.
  7. The nature of online relationships involves therapeutic skills in everyday communication and creates psychotherapeutic processes in non-therapeutic situations.

These new characteristics of online communications affect clients and psychotherapists, illuminating certain similarities between psychotherapeutic procedures and online situations.

MUDs encourage projection and the development of transferences for some of the same reasons that a classical Freudian analytic situation does. Analysts sit behind their patients so they can become disembodied voices. Patients are given space to project onto the analyst thoughts and feelings from the past. In MUDs, the lack of information about the real person to whom one is talking, the silence into which one types, the absence of visual cues, all these encourage projection. This situation leads to exaggerated likes and dislikes, to idealization and demonization.
(Turkle, 1997:207)

Similar understandings were concluded from experiments in virtual support groups:

Transference and Countertransference are important aspects of psychotherapeutic work. The very fact that these groups are held online can change the interactions. For example, because the group members and I do not see each other, members may idealize me or project their fantasies and wishes onto me. Because I am unseen and "mysterious," anger and frustration can be taken out on me more readily.
(Jeri Fink, 1999: 76)

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 Internet makes text relationships more accessible than ever before in history. The unique aspects of text relationships open up new possibilities for online clinical work: reading and writing skills shape the communication; a subjective sense of interpersonal space replaces the importance of geographical space; people can converse with almost anyone online and with multiple partners simultaneously; conversations can be saved and later reexamined; and, the environment is more susceptible to disruption.
(Suler, 2004: 48)

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:

In a storied therapy, the letters are a version of that co-constructed reality called therapy and become the shared property of all the parties to it. Letters can be substituted for case records.
(White & Epston, 1990: 126)

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.
Narrative therapists use letters as a complementary technique. 'A common practice in narrative therapy is to write a letter to the client after a counselling session that is intended as a record of the session and also as a means of building on the developments that have occurred during counselling' (Winslade & Smith, 1997: 166). Narrative therapists also claim that letters (i.e., written communication) are better than face-to-face communication. 'Some narrative counsellors have suggested that a well-composed letter following a therapy session or preceding another can be equal to about five regular sessions' (McKenzie & Monk, 1997: 82). 'David Epston has done an informal survey of people who have worked with him in which he found that on the average they thought a letter was worth 4.5 sessions of good therapy' (Freedman & Combs, 1996: 208). 'David Nylund also did a survey of 40 people who had worked with him. His results showed that the average letter was worth 3.2 interviews' (ibid.). In a way, there is no difference between narrative correspondence and online psychotherapy, and these experiences can be a useful way of learning about the value of online therapy as well.
The importance of letter writing in Narrative psychotherapy is based on the assumption that written texts require a higher state of consciousness.

Stories take on added meaning and permanence when they are written down. They can be re-examined, changed, and edited. The use of the written word seems to render them "more real" and open to analysis.
(Parry & Doan, 1994: 167)

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.

Writing letters offers some of the same benefits as structured storytelling in that it is a known form and is not usually seen as a task as large as writing a story. Yet, letters can capture core events and themes of someone's story.
(Roberts, 1994: 106)

Narrative psychotherapy focuses on the therapeutic aspects of the autobiographic process.

For although therapy is seen as a healing science and autobiography as a literary form, there have always been intimate links between psychotherapy and the restorative powers of personal narrative.
(Rainer, 1997: 14)

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.
Understanding the principles of narrative psychotherapy, the uses of therapeutic letters and the techniques of correspondence may clear up some important aspects of online psychotherapy, and also allay the doubts of its opponents.
Although online psychotherapy is not regarded as narrative psychotherapy, it is impossible to ignore its narrative characteristics or the way it has been influenced by narrative psychotherapy.

Psychotherapeutic machines

Online psychotherapy is associated with personal computers and is frequently misunderstood and confused with the concept of psychotherapeutic computer programmes.
In 1966, when the Internet was taking its first steps, computer scientists from Stanford University developed 'a computer program which can conduct psychotherapeutic dialogue' (Cavanagh, Zack, Shapiro & Wright, 2003: 144). During the same year, Josheph Weizenbaum, of the Massachusetts Institute of Technology, developed a software that plays the role of 'Eliza', a Rogerian psychotherapist (Weizenbaum, 1996). Some versions of Eliza can be found on the net. Following is a sample of a dialogue between 'Eliza' and myself.

> Hello, I am Eliza.
* Hi Eliza. Thank you for listening.
> We were discussing you, not me.
* Oh, I'm sorry. I always feel that no one listens to me.
> Did you come to me because you are sorry, you always feel that no on listens to you?
* Yes. I feel that no one is really interested in what I'm saying.
> Do you often feel that no one is really interested in what you're saying?
* Yes, I do. I feel that at home with my family, at work and even with my friends.
> Do you enjoy feeling that at home with your family, at work and even with your friends?
* No no. I am trying to tell you that I hate feeling not understood.
> Do you believe it is normal to be trying to tell me that you hate feeling not understood?
* Do you say that I am not normal?
> How long have you been not normal?
* Why are you blaming me? You don't understand a word I'm saying.
> Why are you interested in whether or not I am blaming you? Me don't understand a word you're saying?
(Eliza, 1999)

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'.
Kenneth Mark Colby, a psychiatrist from the Stanford University team, developed a more sophisticated software, 'Parry', which could simulate a client in therapy who exhibited paranoid behaviour. 'The Turing test results for PARRY showed that both scientists and psychiatrists did no better than chance in distinguishing PARRY from real patients' (Grohol, 2004: 53). In the transcript of this therapeutic dialogue the psychiatrist comments: 'This has to be the most persistent and patient paranoid I have ever encountered' (Parry, 1973).
The apparently computerised dialogue in psychotherapeutic software was one of the influences leading to online psychotherapy, but it could not bridge the main differences between the two. Psychotherapy is based on the unique bond between therapist and client, while computer software is not. 'Since by definition a computer program cannot form a person-to-person relationship with a client, this might be taken to imply that computerized psychotherapy cannot possibly be effective' (Cavanagh, Shapiro & Zack, 2003: 168). But the influence of computerised psychotherapy on the development of online psychotherapy was even deeper:

The importance of ELIZA and PARRY to online counselling lies in their text-based, interactive nature of communication between human and computer. Researchers discovered not only that individuals could communicate with a computer program and feel as though they were engaging in a conversation, but also that they did so easily and without reinforcement. These programs illustrated some of the very first social uses for computers and demonstrated that people would willingly engage in text-based communication for therapeutic purposes.
(Grohol, 2004: 53)

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.
Psychotherapeutic machines are still far from being a reliable substitute for human psychotherapists. There are some psychotherapists who are starting to believe in the future of online therapy, but there are not many who consider the option of therapeutic software as a substitute for the therapeutic relationship.

Humans need humans. Our interpersonal relationships shape us, ideally for the better. Completely eliminating the therapist's psyche from psychotherapy will be a mistake in many cases. Although computers have some advantages over the human therapist, they are far inferior to people in feeling and reasoning about the human condition. And that's what psychotherapy is all about. Even under the best of circumstances, with very powerful machines, computerized therapy will be second best, most likely limited to highly structured interactions, or to the treatment of mild problems and clients who are healthy enough to cope with a less than fully competent machine.
(Suler, 1999)

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.  

Telephone 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'.

At the time, suicide was still illegal in the UK and so many people who were in difficult situations and who felt suicidal were unable to talk to anyone about it without worrying about the consequences. A confidential emergency service for people "in distress who need spiritual aid" was what Chad felt was needed to address the problems he saw around him. He was, in his own words, "a man willing to listen, with a base and an emergency telephone".
(Samaritans, 2005)

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 number of telephone helplines has increased dramatically with nearly 1300 listed in the latest edition of the Telephone Helplines Association (THA) directory. The research showed the advantages of helplines are their accessibility, availability and anonymity. The telephone is also less intrusive and the caller has control, allowing them to disclose issues at an appropriate time and pace.
(One plus One, 2004)

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:

  1. Single parents and those with young children and no childcare.
  2. eople with a disability.
  3. Older people who may be afraid of going into busy town centres.
  4. People living in remote areas.
  5. People caring for disabled or infirm relatives.
  6. Those who find transport difficult.
  7. Those whose personal freedom is restricted by another person such as abused women or children.
  8. People on a low income or in receipt of state support who may find that transport costs are higher than the price of a 30 minute phone call.

This list also perfectly describes people who need online therapy, and for the same reasons. 
The same arguments against online psychotherapy were made against counselling by telephone (Rosenfield, 1997: 3), but since 1994 the BAC acknowledges telephone counselling through its National Vocational Qualification process (ibid.). It is interesting to note that while online therapy, which is developing fast, is still controversial, telephone counselling is becoming a respectable psychotherapeutic field:

It seems incredible that as recently as 1997, some practitioners regarded therapy by telephone, anecdotally, as "not real therapy", and even with some derision. Yet today, many practitioners use the telephone for some or all counselling and psychotherapy sessions and also for supervision.
(Rosenfield, 2003: 93)

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.

Stuart Klein, 1997, has hypothesized that the lack of visual cues intensifies the need to listen and the ability to listen. He points out this theory is supported by information processing research. And he notes Lester's (1995) research, which reported the lack of nonverbal cues is nothing new in counseling roles in society. Psychoanalysis, where the analyst sits out of view of the patient, and Catholic confessions are illustrative examples.
(Grohol, 1997)

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.

People work more freely when they feel they are not being judged and feel safe and this happens quite early on in the telephone counselling relationship, thus it may take fewer sessions to achieve the goals of the therapy than would face-to-face work.
(ibid.: 108)

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.

Delivery of services by such media as telephone, teleconferencing and internet is a rapidly evolving area. This will be the subject of APA task forces and will be considered in future revision of the Ethics Code. Until such time as a more definitive judgment is available, the Ethics Committee recommends that psychologists follow Standard 1.04c, Boundaries of Competence, which indicates that "In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm".
(APA, 1997)

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:

We conducted a comprehensive review of the telepsychiatry literature from 1965 to June 2003, using Medline, PubMed, PsycINFO, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases. The Journal of Telehealth and Telecare was also hand searched for the years during which it was not included on Medline. Key words included telepsychiatry, telemedicine, video-conferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care and costs. The first author reviewed article titles and abstracts to decide whether they applied to the theme of effectiveness. Selected articles were pulled, and references were reviewed for potential additional articles.
(Hilty, 2003)

The conclusions of this review were very positive:

Telepsychiatry appears effective, based on the preliminary data on access to care, quality of care (that is, outcomes, diagnosis and ability for users to communicate), satisfaction and education. It also empowers patients, providers and communities. It is premature to claim that telepsychiatry is cost-effective. Technology and program coordination are important determinants to its short- and long-term viability.
The results of this article appear similar to a review of 66 studies that compared telemedicine with a comparison group with respect to administrative changes, patient outcomes and economic issues. Thirty-seven (56 per cent) suggested that telemedicine had advantages over the alternative approach; 24 (36 per cent) found negative issues or were unable to draw conclusions, and five (eight per cent) found alternatives to be superior.

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).
Investigators who compared videoconferencing to telephone counselling and face-to-face therapy didn't find significant differences between the three modes of psychotherapy (Wittson and Benschoter, 1972, Schneider, 1999, Hufford, Glueckaur & Webb, 1999, Day and Schneider, 2002). The findings of some studies regarding therapists' preferences (Nagel and Yellowlees, 1995, McLaren et al., 1996, Omodei and McClennan, 1998, Simpson et al., 2001, Mitchell et al., 2003) show that 'Although therapists often tend to be more cautious about video therapy than clients, this initial reluctance tends to recede with experience and practice' (Simpson, 2003: 116). Simpson (2001) found that clients preferred video therapy to face-to-face sessions:

Some clients felt that they were more easily able to express difficult feelings via video-conferencing and that the extra distance made them feel safer. Similar results were found by Bakke et al. (2001) who treated two women with bulimia nervosa via videoconferencing, using a manual-based cognitive-behavioural model. Results showed that clients valued the privacy and anonymity of video therapy, and they commented that it was less intimidating than face-to-face sessions.
(Simpson, 2003: 113)

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).
Although it can be assumed that online videoconferencing would be a natural development of the approved telehealth, online psychotherapy is still far from employing this technique. In 1994-1995, when psychotherapists started using the Internet for therapeutic intervention, written communication was available to millions of surfers while, in 2005, online videoconferencing software and hardware is still complicated. Even online telephony is relatively rare, although it has become more popular in the last two years. This explains why online therapy is still based on written messages, either via e-mail or chat rooms.
Interestingly, psychotherapists' resistance to online psychotherapy can be reduced to the fact that it is not a videoconferencing form of communication (e.g., that it lacks physical cues). The history of videoconferencing in psychiatry could strengthen the development of improved online psychotherapy, which combines written sessions, telephone communication and video-conferencing. But this course of development is not guaranteed, due to psychotherapists' disregard by videoconferencing in individual therapy.
Nevertheless, comparative research on telephone communication, videoconferencing and face-to-face therapy will serve to assess and value the new options of online psychotherapy.
Online psychotherapy offers new horizons for videoconferencing, since it broadens its synchronic (simultaneous) setting with the possibilities of asynchronous (time-delayed) communication. This new kind of communication affects the therapeutic relationship and enables full documentation of the process.

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.

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, though the magic that creates this in one group but not another is not entirely clear…
Some people develop extremely deep commitments to their online groupmates and the ties may become far stronger than those that link the individual to real-life groups.
(Wallace, 1999: 56, 57)

From its early days the Internet functioned as a support-group for many surfers in various ways (Colon & Friedman, 2003: 60).

1. From the 1960s to the 1980s, before the creation of the Web, the Usenet functioned as a discussion area, in which numerous newsgroups were conducted.

Newsgroups are also public discussion forums on the Internet. Unlike mailing lists, you access them through special software called a "news reader"… Newsgroups' advantages over mailing lists are that the format naturally supports 'threading'. A threaded discussion is one where you can read all of the messages on a particular topic more easily because they follow one another in order under that topic's title.
(Grohol, 1999: 9).

Newsgroups with the suffix 'alt.support' were dedicated to peer support groups, and 'thousands of people participated, and continue to participate in this mutual aid community' (Colon & Friedman, 2003: 60). One of the first online support group, alt.support.depression, started on the Usenet, and until 1995, hundreds of such groups founded. (Grohol, 2004: 55).

2. The use of personal computers in the 1970s was followed by the world's first BBSs (Bulletin Board Systems). 'A bulletin board is a program or location on the World Wide Web in which participants can read and write messages at any time that can be read by any other participant. The messages remain for the duration of the group, posted sequentially and usually organized by topic' (Colon & Friedman, 2003: 60). The BBSs increased rapidly. 'Boardwatch magazine estimates that sixty thousand BBSs operated in the United States alone in 1993, fourteen years after the first BBSs opened in Chicago and California' (Rheingold, 1993: 9).

3. Bitnet Relay Chat was used from the early days of the Internet, and enabled users to correspond in real-time (synchronous). It became a practical instrument for the public in 1988, when Jarkko Oikarinen (Oikarinen, 2000) developed the IRC (Internet Relay Chat), a multi-user programme for group communication.

Text-chat allows you to communicate dynamically with somebody in realtime via the Internet. Whereas Email requires that you send a message in a big chunk, text-chat communications proceed line by line.
(Zack, 2004: 106)

Actually, an online chat imitates a face-to-face conversation. There is only one essential difference: the text stays there, on the screen, as silent witness to the whole process.

Although some rooms open up for a short time and then disappear, many have been in existence for years. Conversations go on 24 hours a day, 365 days a year, and the "regulars" bearing well-known nicknames, frequent the places.
(Wallace, 1999: 6)

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).

A mailing list is a private email subscription in which each subscriber receives a separate copy, via email, of each message that is posted, either in individual or digest form each day, week or month. Through these messages members can maintain ongoing communication with other list members who share a particular diagnosis or common concern.
(Colon & Friedman, 2003: 61)

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.).
Online self-help groups preceded online psychotherapy by two decades. These groups were helpful for people who could not attend traditional meetings, due to physical disability, transportation difficulties or lack of a suitable face-to-face group. Online self-help groups offer 24-hour availability, anonymity, and accessibility from home:

The last few decades have seen an enormous growth of self-help groups. The principle at the core of this approach is the sharing of experiences, strengths and hopes between members in order to solve their common problem. These groups offer both an alternative and adjunct to the traditional psychotherapy approach. A summary of what online self-help groups offer its members is provided by Madara (1990). Madara explains that social support, practical information, shared experiences, positive role models, helper therapy, empowerment, professional support, and advocacy efforts are all factors that operate online, just as they do in face to face groups.
(Castelnuovo & Gaggioli, 2003)

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.

In general the effectiveness of online self-help groups is high: different researchers proved their efficacy as support tools in the treatment of eating disorders (Zabinski, Pung, Wilfley, Eppstein, Winzelberg, Celio and Taylor: 2001, Celio, Winzelberg, Wilfley, Eppstein-Herald, Springer, Dev, and Taylor: 2000), depression (Dyer, K.A. and Thompson, C.D.: 2000) and headache (Stroem, L., Pettersson, R. and Andersson, G., (2000).
(Castelnuovo & Gaggioli, 2003)

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.

An informal data analysis of this inventory indicated that participants' psychosocial distress, especially anxiety and depression, lessened over the span of the group. Overall, participants found the online group experience to be a positive one.

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.
Online group psychotherapy, run by professional therapists was the last stage in this development, preparing the ground for online psychotherapy. 

On-line self-help support groups were the precursor to e-therapy; the enduring success of these groups has firmly established the potential of computer-mediated communication to enable discussion of sensitive personal issues. Local computer bulletin board systems began to develop not long after the introduction of the first personal computers in 1976; it is not unreasonable to assume that small, informal support groups gathered on some of them.
(Ainsworth, 2001)

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.

What all of these online forums shared was the ability to bring together individuals from around the world into a virtual community. Although the technologies of these communities differed significantly, their basic social underpinnings were similar, bringing together people from around the world to communicate through computers. People found it simple, rewarding, and nearly limitless in its potential to change many social conventions.
(Grohol, 2004: 57)

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:

Therapists who have worked in an online setting are usually surprised at how quickly and how much they can learn about clients through the written word. Emotions and feelings become easily recognizable. The therapist can often discern when a client is ill, intoxicated, or depressed, and may even uncover untruth by "reading between the lines". Therapists have discovered that levels of intimacy and trust may be greater because participants feel more comfortable disclosing and discussing their most intimate concerns. In asynchronous communications, clients are able to give the time and thought to their writings, which provide richer and more meaningful responses.
(Bellafoire, Colón & Rosenberg: 2004)

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.
Where a need appears, there is always someone to fulfil it. Support groups, facilitated by professional therapists, were the first source of psychotherapeutic information. In a way, the Internet replaces traditional publishing procedures, and enables psychotherapists, as well as anyone else, to publish their material directly for their clients without the mediation of a publishing house.
It is difficult to know when psychotherapists started to interact with clients online, since this sort of professional communication is confidential. One can assume that when therapists started offering their services on the net in 1979, 'when the first national online services (The Source and CompuServe) allowed nationwide online communication for personal computer users' (Ainsworth, 2002: 205), clients started asking them for their advice. The first organised service providing free advice-giving by psychotherapists through the Internet was at Cornell University in Ithaca, NY. Jerry Feist, the Assistant Dean of Students and former Director of the Cornell Counselling Center, and Steve Worona developed a system named 'Dear Uncle Ezra':

Two dozen public computer sites around campus provided free access to students to ask and read Uncle Ezra inquiries (as a part of the campus-wide Cornell University Information System, Cuinfo). The queries were answered by university workers and posted on the university's proprietary computer system for all to read. The service (still in use, having been transferred to the Web in the 1990s) is free but only provides simple, advice-driven answers; in-depth consultations aren't available through the system.
(Grohol, 2004: 58)

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.
Ivan Goldberg, a psychiatrist and psychopharmacologist, started to answer online questions about the medical treatment of depression in 1993. He did this as unofficial advisor to an online depression support group, 'Walkers in Darkness'. In 1996 he created his own site, 'Depression Central'.
The charity organisation, 'the Samaritans', has given free-advice over the telephone since 1953. In 1994, they set up an e-mail address to answer e-mails from suicidal individuals worldwide. In 2003 this e-mail service replied to 99,000 queries (Samaritans, 2003).
Free advice-giving can be technical, cold and formal, efficient and impersonal, as is the case in many non-therapeutic free-advice online services. Psychotherapeutic advice-giving has always involved emotional aspects and no advice can escape a kind of therapeutic intervention. The tendency towards therapeutic intervention is a trap for therapists who give advice through the Internet but, at the same time, it serves as a natural process of involvement in online therapy. I can testify to my own experience in such a situation.
In 2000, together with a psychiatrist, I facilitated a public forum for psychiatry and psychotherapy. The forum was part of a 'doctors' site, one of dozens, led by professional health experts. Although the psychiatrist's answers were phrased in unambiguous, impersonal messages, I could not avoid being empathic, responding to personal needs and encouraging relationships and support between participants. Within a short time this open forum became a dynamic group with psychotherapeutic characteristics. This was my first introduction to the therapeutic aspects of online relationships, and it subsequently shaped my skills as an e-therapist.
For the last four years, I have participated in a forum for professional psychotherapists, most of them clinical psychologists who volunteer as facilitators for  'psychological' public forums. There are no more than two or three online therapists in Israel (myself included), and most of the psychologists are resistant to the idea of e-therapy. Our forum has about forty members, most of whom reject online therapy. Nevertheless, their experiences with online support groups and their coping with inevitable therapeutic intervention, have diminished their prejudices and have brought them closer to some manifestations of online psychotherapy. Some of them integrate e-mail exchange with face-to-face psychotherapy, or create therapeutic relationships with new clients through online correspondence.
On the other hand, contemporary clients are more educated, and online psychotherapeutic information causes them to be better prepared and ready to start therapy. They have wide knowledge of therapeutic approaches and techniques and are aware of the differences between various kinds of therapists. Online self-help groups and online support groups introduce them to therapeutic processes and allow them to learn from other participants' experiences. They can even consult with professional therapists or group members about their own therapist's work and capacities. Sometimes, this well-informed and semi-professional knowledge can interfere with face-to-face traditional therapy, and therapists must be prepared for a new generation of clients.
Online free-advice giving is changing the world of psychotherapy. It not only influences the attitude of conservative therapists towards the fast evolution of online therapy but also has implications for therapeutic relationships in traditional settings. Educated clients need more educated therapists and the role of therapists as professional authorities is being replaced by more egalitarian relationships.

Online fee-based psychotherapy

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.
Martha Answorth (2002: 205) claims that the first fee-based mental health services started in 1995, while John Grohol (2004: 59) believes that it all started in 1994.

There was no single "first" psychotherapist who began offering his or her services online for a fee; many professionals began around the same time in different parts of the world. A few therapists, however, are repeatedly mentioned and recognized as being among the first online counselors.
(Grohol, 2004: 59)

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.
Dr. David Sommers was the first online psychotherapist to offer an ongoing therapeutic process through the Internet. From 1995 through 1998 than 300 clients from all over the world utilized his services (Ainsworth, 2002: 206). His practice was based on e-mail correspondence, real-time chat (IRC) and video-conferencing.
Ed Needham was the first therapist to work exclusively as a chat-room therapist. In August 1995, he started his site, 'Cyberpsych counselling service', charging $15 per one-hour session. From 1995 to 1998 he worked with 44 clients, but in 1998 he closed his online service.
Richard Sansbury started his online practice in 1997 and, to this day, provides e-mail therapy for 1$ per minute of his writing time (www.headworks.com).
I have been practising online psychotherapy since 1999. I started with e-mail therapy, experienced chat-room therapy and developed a virtual clinic, which is a special forum that is meant to be a 'secure frame' for the therapeutic process (sometimes integrated with online phone). I practice 'forum therapy' in a way that is similar to my face-to-face practice and my online fees are almost identical with my face-to-face fees.
Following the steps of the pioneers in fee-based online psychotherapy, many other therapists became involved in online therapy, and founded online clinics.

In the fall of 1995, when I did my own search, I found 12 e-therapists practicing on the Internet. My database has now grown to include over 300 private-practice Web sites where e-therapists offer services and the newer "e-clinics," which represent, collectively, nearly 500 more e-therapists. And the number is growing.
(Ainsworth, 2002: 206)

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.
In 1997, professional online therapists and consumers, like Martha Ainsworth, founded ISMHO (International Society for Mental Health Online), to promote online psychotherapy. In June 2005 there were about 200 members. Members use ISMHO's logo as a stamp of approval on their private sites.

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.

Today, e-therapy has found a niche. It is not a large niche, nor one that will attract millions of dollars in investment capital. Some small online networks of mental health practitioners continue to thrive and will likely gradually grow as more and more people learn of the benefits of online mental health services.
(Grohol, 2004: 65)

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.

Over the course of 4 years, I have offered on my site a consumer satisfaction survey, which has yielded some interesting information. In May 1999, out of 619 total responses, 452 respondents (73%) had tried e-therapy. Of those, 416 (92%) said that it had helped them, and 307(68%) said that they had never been in therapy before contacting a therapist via the Internet.
(Ainsworth, 2002: 208)


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.
However, videoconferencing does not actually play a central role in online psychotherapy and although online telephony is also accessible to all Internet surfers, most therapists and clients prefer written interaction.
This is a paradoxical phenomenon. On the one hand, the main argument that is generally presented against online psychotherapy by most online psychotherapists is its lack of physical cues. On the other hand, they tend to stick to written communication. This can be explained by therapists' conservatism, their fear of new technical devices or their clients' preference for written sessions.

 As broadband Internet connections become available to more consumers, videoconferencing and Internet phone are increasingly available. Even so, many consumers continue to prefer the nonvisual, nonvoice, low-tech environment of e-mail and chat, finding it easier to communicate about sensitive issues without visual or voice connection.
(Ainsworth, 2002: 207)

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.
The textual nature of online psychotherapy is realised in three main types of online settings. The first one is based on asynchronous communications by electronic mail (e-mail), and the second is based on synchronic communication through a chat-room. The third integrates both e-mail and chat therapy, functioning in support groups or group psychotherapy but not in individual therapy. 

1. Chat room psychotherapy.

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:

Therapist: This is the first time you are talking about your father.
Client: I didn't mean to, well, I did and I didn't. I mean, I didn't want to talk about him today, and now that you're asking I can't think about anything else. :(
Therapist: I see..
Client: No, YOU DON’T.
Client: I hate this 'I see'! He always said that, when I needed his advice. He would never tell me what he thought, never support me. He'd just sit there, like you, saying nothing and then this cold and distant 'I see'. (I can see you now sitting on your chair, playing Solitaire while listening to me, and saying 'Aha', or 'I see', so I think that you're listening, but you aren't).
Therapist: That was a very powerful and touching image of your father and the way you direct your anger at me. While reading, I momentarily felt like your father, experiencing the frustration of wanting to hug you and at the same time being scared of your reaction.

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.
There is an essential difference between chat room therapy and face-to-face therapy. Written interaction is by definition a conscious process and as such it is more intense and deep. The written text stays there, on the screen, a silent witness to the whole process, and both parties can read it all again and again. They can also 'save' the text to their computers and document the whole process. The documentation replaces the classical case study with the exact data of the session and is not subjective as are classical case studies.

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.
E-mail therapy is an asynchronous interaction, which is entirely different from face-to-face therapy. Actually there is no real dialogue, but an exchange of two monologues. There are different time frames, different settings and different personal processes.

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.
There is no spontaneity in e-mail therapy and each e-mail is probably re-read and edited before being sent. This process demands skills and intentions on the part of therapist and client alike that are not always necessary in face-to-face psychotherapy, such as writing skills, analytic thinking and self-awareness. Actually, this technique is more suitable for supervision and is more productive for ex-clients who want to continue the therapeutic process in a more remote setting. Clients who need support or guidance might feel detached, abandoned or neglected, although for people who avoid therapy due to questions of trust or stigma, e-mail therapy could possible pave the way for face-to-face therapy.

To many people, the Internet feels more private, and this perceived privacy helps them get past the barrier of stigma to seek help through e-therapy. Interestingly, in my survey, of the 307 persons for whom e-therapy was their first contact with a therapist, 197 (64%) eventually moved on to consult a therapist in person.
(Ainsworth, 2002: 209)

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.

E-mail is not just electronic mail sent via the Internet. E-mail communication creates a psychological space in which pairs of people - or groups of people - interact. It creates a context and boundary in which human relationships can unfold.
(Suler, 1998)

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.

3. Discussion group therapy.

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.
The characteristics of discussion groups, or forums, integrate the advantages of chat room and e-mail communication, and they seem to create an appropriate setting for online psychotherapy, which could replace the aforementioned two common types. This has not yet happened. Chat room and e-mail programmes are more accessible; furthermore, psychotherapists are accustomed to them.  A secure forum (with a password) for private use is available to therapists, but adjusting it to therapeutic uses might require an investment of time and money.

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.

Controversial aspects of online psychotherapy 

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.
Although the psychotherapeutic establishment is becoming more accepting of online psychotherapy, it is important to examine the arguments for and against this new kind of psychotherapeutic environment.

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.

As complex and meaningful as text communication can be, it lacks the amount of robust and rich information that can be conveyed via the integration of talking, facial expressions, voice intonation, body language, and physical contact.
(Suler, 1998b)

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:

In the typed text of e-mail, you can't see other people's faces or hear them speak. All those subtle voice and body language cues are lost, which can make the nuances of communicating more difficult. But humans are creative beings. Avid e-mailers have developed all sorts of innovative strategies for expressing themselves through typed text. A skilled writer may be able to communicate considerable depth and subtlety in the deceptively simple written word. Despite the lack of face-to-face cues, conversing via e-mail has evolved into a sophisticated, expressive art form.
(Schneider, 1995: Chapter Two)

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.
Sometimes, the physical dimension of psychotherapy is diminished as part of the theoretical assumptions. The main characteristics of Freud's psychoanalytic setting  (neutrality, transference, and the couch) do not involve physical interaction. Freud's setting is a non-physical situation, in which body language plays no role at all. The couch indicates the boundaries of this non-physical setting, prevents visual and physical contact between patient and analyst and provides a neutral platform for free association and ‘pure’ transference.

Since, while I listen, I resign myself to the control of my unconscious thoughts I do not wish my expression to give the patient indications which he may interpret or which may influence him in his communications. The patient usually regards being required to take up this position as a hardship and objects to it, especially when scoptophilia plays an important part in the neurosis.
(Freud, 1913: 354)

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 such an environment was impossible in Freud's times, it was forgotten, and pure transference was never achieved or explored. Later developments in psychoanalysis were focused on 'real relationship' (Greenberg and Mitchell, 1983: 156), 'through which the capacity for making direct and full contact with real other human beings is restored' (ibid.). In other therapeutic approaches, such as the behavioural approach, physical interaction plays a central role in the therapeutic process.
While an absolute neutral setting was impossible in Freud's times, the new online setting is the first opportunity to research and explore Freud's assumptions concerning transference and neutrality.

Since, while I listen, I resign myself to the control of my unconscious thoughts I do not wish my expression to give the patient indications which he may interpret or which may influence him in his communications. The patient usually regards being required to take up this position as a hardship and objects to it, especially when scoptophilia plays an important part in the neurosis.
(Freud, 1913: 354)

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:

Analysts sit behind their patients so they can become disembodied voices. Patients are given space to project onto the analyst thoughts and feelings from the past. In MUDs, the lack of information about the real person to whom one is talking, the silence into which one types, the absence of visual cues, all these encourage projection. This situation leads to exaggerated likes and dislikes, to idealization and demonization.
(Turkle, 1997: 207)

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).
Experienced online therapists believe that textual interactions create their own virtual 'body language':

As human factor engineers will tell us, the visual interface of our communication software also affects how we think, perceive, and express ourselves. Clinicians might be wise to compare software before choosing one for their work.
(Suler, 2004: 25)

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'.

Messages can vary widely in length, organization, the flow of ideas, spelling errors, grammar sophistications, the spacing of paragraphs, the use of quoted text, caps, tabs, emoticons and other unique keyboard characters, as well as in the overall visual "feel" of the message. As I mentioned earlier I this chapter, the structure of the email body reflects the cognitive and personality style of the individual who creates it.

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 claim that the lack of physical cues in online psychotherapy is an intrinsic disadvantage denies the significant role of case studies in supervision and psychotherapeutic theories, since these cannot present the physical dimensions of the therapeutic process. It also denies the value of case studies based on textual documentation, like Freud's 'Godiva'  (1907), 'Little Hans' (1909) and Schreber (1912).

Ethical considerations

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).

1. Competency
Online therapy is not yet an independent profession, and it is difficult to define the professional skills of an online therapist. An online therapist can be a trained face-to-face psychotherapist, a clinical psychologist, a psychiatrist, a social worker, a drama therapist or art therapist, but these credentials do not guarantee that the therapist will be competent to practice online psychotherapy.
Although there are some training courses for online therapists (OnlineCounsellors, e-Therapy Training), these private courses are not yet accredited by academic institutions or professional organisations. ISMHO members copy its logo onto their sites as a stamp of approval, but ISMHO is not a professional society, since it includes therapists and consumers, and 'does not endorse or hold any official position about the legitimacy or usefulness of e-therapy' (ISMHO, 2005).
The new formulations of certain codes of ethics concerning online psychotherapy can guide psychotherapists in adapting their professional code of ethics to their online work, but do not require them to prove their competency as online therapists.
Due to the textual characteristics of online communication, competency in online psychotherapy means more than therapeutic skills.

We must keep in mind the nuts and bolts of providing online psychotherapy – the therapist must be able to type; to spell; to use appropriate grammar; to be able to get around online. As mentioned above, even the most renowned and respected therapist won’t get too far in this process if they can’t type, spell or at a more basic level navigate on the computer.
(Stofle, 1997)

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.
Before they choose to practice online psychotherapy, it is important for therapists to examine whether they are suitable to practice this type of therapy.

First and foremost, online practice is for those who love it. If you are deeply skeptical about making emotional connections through the written word in the absence of visual cues, then online counseling is not for you. Being nervous around technology, a laborious typist, or feeling reluctant to explore the Internet are other examples of not being suited to the medium.
(Zelvin & Speyer, 2004)

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.

2. Confidentiality.
As is true of face-to-face psychotherapy, online therapists are committed to confidentiality as stipulated by their written therapeutic contracts.

Everything which you disclose to me will remain confidential, except in exceptional circumstances (see below).
As a BACP (British Association for Counselling and Psychotherapy) member I am bound by BACP’s Code of Ethics and Practice and its Complaints Procedure. Regarding confidentiality, the BACP states that counsellors must offer the highest possible levels of confidentiality in order to respect the client’s privacy and create the trust necessary for counselling. However, in exceptional circumstances, where there are good grounds for believing that serious harm may occur to the client (i.e., you) or to other people (including children), and / or where there are good grounds for believing that the client is no longer willing or able to take responsibility for his / her actions, confidentiality may be broken. I would attempt to discuss this fully with the client first.
Although this service is confidential, I cannot give a 100% guarantee of internet and telephone security by the operating companies or other users.

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.

Confidentiality is not an absolute. It never has been in the real world, nor should it be held up to an impossible or ideal standard in the online world.
(Grohol, 1999)

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.

Talking to a therapist online is probably as safe as talking to one in person. Both are very confidential, and neither is 100% perfect.
(Ainsworth, 2001a)

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.
One of the online therapists' duties is to educate their clients and teach them how to increase the confidentiality level. They can do this by encrypting their e-mail, using a password to access their personal files, not printing their therapeutic sessions on paper, not using public computers for therapeutic communication and, checking addresses before sending e-mails, etc.
My experience has taught me that the level of online confidentiality is not high enough for famous clients. Any mistake can endanger their privacy, and it is better not to offer them online psychotherapy.
While confidentiality is associated with subjective beliefs of therapists and clients concerning the security of the therapeutic interaction in face-to-face or online psychotherapy, online therapy is associated with technophobia, and this intensifies the objective limitations of security in online communication. This means that online psychotherapists should be aware of the technological aspects of each kind of online communication and inform their clients about the level of security they can offer them. 'There are security measures such as using a secure socket layer (SSL) for the submission of sensitive material and financial information. Widely available encryption software can be used to safeguard email and protect client records' (Chechele and Stofle, 2003: 44).
The most confidential online communication is a chat interaction in a secure site, on which the texts are not stored. 'All messages must be encrypted at 128-bit cipher strength, and the computer servers of the provider of the chat software must not be used to store the messages' (Derrig-Palumbo and Zeine, 2005: 205). Actually, such interaction happens in a secure location, and there are no transfers of texts out of the site.
Although e-mail communication can also be encrypted, it always involves information transfers between computers, which can be viewed by third parties. 'Finally, e-mail is not secure. Even "secure" e-mail has vulnerabilities… There are too many ways for confidentiality to be breached when using e-mail’ (Ibid.: 206). On the other hand, ‘although security systems are never totally perfect, when the client and clinician both use encryption while communicating, privacy is increased' (Kraus, Zack & Stricker, 2004: 134).
The relations between the level of security in online therapy and the subjective sense of a ‘secure frame’ is not self-evident, since 'experience shows that many clients do not worry much about confidentiality when using regular email' (Kraus, 2004: 134). Text documentation may not be 100% secure, but it has other benefits for creating a secure frame. Paradoxically, e-mail communication is less secure than chat room psychotherapy, but nevertheless it is the most popular setting for online therapy. This means that the technical devices of creating security are less important than the subjective sense of confidentiality, which is created by a certain combination of the elements of the therapeutic relationship (the ground rules).

3. Benefits.
The first command of any code of ethics is a commitment to promote the clients' well being (or to 'do no harm'). Does online psychotherapy promote clients' well being?
There are several answers to this question. Conservative psychotherapists who resist the idea of online psychotherapy believe that this is not psychotherapy, since it lacks physical cues. If physical cues are essential for competent therapeutic work, online therapy cannot be sufficient to fulfil clients' needs.
Resistance from the professional field can shift the question of benefit from its main target, the client. Online psychotherapy is not beneficial to all clients, and therapists should consider this when interviewing new online clients.

Online therapy will not be appropriate for all people seeking help. In these cases, the online practitioner should have the skills and resources to make appropriate referrals. When the practitioner determines that high risk or other factors indicate that a person is best served by seeking immediate treatment within his or her locality (e.g., for suicide prevention, medication assessment, etc.), such a referral or assistance in finding an appropriate referral should be provided.
(ISMHO, 2001)

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.
Online psychotherapy can be beneficial to clients with physical disabilities, those who are looking for a special therapist they cannot find locally (language, religion, gender, etc.) those who are apprehensive of the stigma of face-to-face psychotherapy or anyone who wants to explore his/her inner life and is interested in personal growth.

4. Legal aspects.
The Internet has no territory and its global accessibility blurs national borders and legal boundaries. Internet surfers gather together with other surfers in a virtual community that has no legal authority, but is guided by the unenforced code of ethics for written behaviour on the net, the Netiquette (Netiquette, 2004).
This situation, in which online "Netizens" (citizens of cyberspace) have no common regulations for their virtual interactions, while each of them is bound by his country's (or state's) laws, is frustrating and sometimes dangerous. This situation is even more confusing for online therapists, many of whom will refrain from any professional online activity until such time as the legal aspects of online psychotherapy are defined:

One of the inherent qualities of the Internet is the way that it dissolves geographical boundaries. The physical distance between two persons is irrelevant to Internet communication. The Internet makes it possible for counselors to reach underserved populations who might otherwise have little or no access to care. It potentially allows everyone access to mental health care, regardless of his or her geographical location or that of the provider. A psychologist in Maryland can treat a depressed patient above the Arctic Circle. An isolated Nebraska farmer can talk to a therapist in New York City. An American in Kuwait can get help from a counselor back home. These are exciting possibilities, but existing licensure laws were not designed to account for such global interactions.
(Holmes & Ainsworth, 2004: 264)

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.
The question of licensure is one of the main difficulties in online psychotherapy.

In the absence of national licensure and with few state reciprocity policies, the lawful practice of e-therapy is considerably hampered by state licensure laws and, equally as important, by the practices of the state boards that investigate and discipline doctors and other therapists.
(Terry, 2002: 171)

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.

I consent to the conditions of e-mail counseling (services and billing) as described above, and to the confidentiality limitations. I understand that this is not psychotherapy but a service for support and coaching.
(Counseling Cafe)

Other online therapists differentiate between psychotherapy and counselling by claiming that psychotherapy is more directive than counselling.

Online counseling is considered experimental at this point. Because a therapist cannot see or hear clients in cyberspace, there are many important clues that are missing using this medium. These visual and auditory clues include, facial expression, body language, and the tone of voice. Therefore, the therapist's perceptions are limited by the written information the client supplies. Because of this limitation, online consulting is not a therapy. Therefore people in need of a therapeutic relationship must seek treatment from a licensed professional within their own community.
(The Counseling Connection)

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:

Internet Therapy and Phone Therapy is not intended to replace face-to-face therapy with a professional therapist. The pros and cons of using this service need to be fully considered when determining if cyber therapy is right for you.

5. Insurance.
The unsolved question of licensing overlaps the question of insurance and malpractice. Online psychotherapy is still new, so many professional liability insurance companies do not cover this sort of practice.
Although some companies do cover such activities, they stipulate that they must fall within the limits of the professional licence. This limitation can narrow therapists' possibilities if the license does not recognise online psychotherapy or if it is limited to a geographic area, as holds true in the USA.
These limitations supply another explanation for online therapists' tendency to protect themselves by declaring that online therapy or online counselling is not real 'psychotherapy'.
How these evasive statements affect the creation of therapeutic trust between therapists and clients has not yet been examined.


6. Anonymity.
In online psychotherapy, where therapists do not meet their clients face-to-face, clients can keep their anonymity and avoid revealing their personal details to the therapist.

On the other hand, it is an alternative which offers confidentiality (to the extent allowed by law) and anonymity if that's the only way the client will seek help.
(The WebCounseling Site)

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.
But there is another kind of anonymity in the new setting of online psychotherapy, the anonymity of the therapist, which resembled Freud's recommendations to psychoanalysts:

The physician should be impenetrable to the patient, and, like a mirror, reflect nothing but what is shown to him.
(Freud, 1912: 331)

The reason for Freud's recommendation was that

Realistic knowledge about the analyst interferes with the formation of transference illusions. The analyst is expected to be a relatively blank 'screen' upon which the patient can freely project his or her infantile fantasies.
(Smith, 1991: 180)

Therapists' anonymity can enhance the phenomenon of transference, in psychoanalytic terms, or guard clients from frame deviations by practitioners, in communicative psychotherapy terms:

The reason for this appears to be that at the very least self-revelations violate the "patient-centered" component of neutrality – the non-anonymous analyst "hogs" the therapeutic space – and at worst involves an implicit role-reversal and appeal for psychotherapeutic help from the patient.
(ibid.: 181)

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.

7. Technical difficulties.
In online psychotherapy there is always a third party that significantly influences the therapeutic process. This is the technical device, without which the therapeutic interaction cannot exist.
The role of computers, telephone lines and Internet providers is central and its image significantly influences both client and therapist. This third party can be a threatening factor for online clients and can deter potential clients, therefore it has to be discussed and interpreted privately and in public.
The role of technology in online psychotherapy changes the classical structure of the therapeutic setting and forces therapists and clients to cope with the never-ending development of the web.

8. Crisis management.
The intimate therapeutic relationships between therapists and clients in face-to-face psychotherapy create a delusion regarding care and safekeeping. Some therapists share these delusions by being ready to break the therapeutic framework and help their clients in times of crisis in their everyday lives.
Actually, psychotherapists are always remote from their clients and cannot be accessible whenever needed. In times of crisis, they probably ask the help of other professionals who can take care of the clients.
Online psychotherapists do the same, but the image of virtual communications has shattered delusions about the omnipotent therapist and raised another claim against online psychotherapy.
I cope with this dangerous delusion by exploring it with my clients in the first session and by keeping a record of clients' information (address, telephone number, etc.) for potential crisis intervention.

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.
Since therapists cannot really manipulate their clients' minds, as physicians do with clients' bodies, the therapeutic process is always limited to the relationships between clients and therapists. The goal of this relationship is to create a 'secure frame', in which clients can explore the issues they bring to this situation and develop their own capacities to confront their weaknesses
Online psychotherapy is limited to a narrow situation in which nothing exists but written messages (narratives). These written messages, which are the only evidence of the therapeutic process, can serve as objective data for scientific research in online psychotherapy. Such objective data has never been accessible in traditional psychotherapy.
The availability of these data for both therapists and clients constitutes the revolutionary aspect of online psychotherapy. Thus, earlier dialogues are always accessible to both sides. This aspect changes the therapeutic relationship and has to be considered in any further thinking concerning the future of online psychotherapy or traditional psychotherapy.
The documentation of online therapy sessions replaces the traditional case study. Unlike the subjective style of classical therapeutic case studies, written correspondence between therapist and client represent the exact therapeutic process in an objective manner.
Since the case study is available to therapists in the process of communicating with their clients, they can use it as a didactic instrument to enrich their work by self-supervision and by sharing their conclusions with their clients. This will change the nature of the therapeutic encounter and increase conscious processes that can accelerate the therapeutic process.


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.
The short history of online psychotherapy is surprising and unexpected. There is no explanation for why psychotherapists were not influenced by telepsychiatry and telephone help-lines long before the Internet revolution. There is no explanation for why they don't adopt some of telemedicine's achievements in ethical codes and licensing.
Although the main argument against online psychotherapy is its lack of physical cues and body language, online psychotherapists have ignored the advanced technical options that allow the reproduction of face-to-face psychotherapy through the Internet, instead choosing to stick to the primitive options of online correspondence or chat-room interaction.
This surprising course in the evolution of online psychotherapy can be explained as coincidental or interpreted as an expression of conservatism, but it also can be understood as a remarkable shift in the history of telemedicine. Perhaps the qualities of textual interactions, still the main actor in the Internet information revolution, have defeated sophisticated audio-visual online devices.
It would appear that text-based communication is the natural selection for online psychotherapy, which brings us back to the origins of the talking-cure.
The present situation of online psychotherapy, which mainly consists of e-mail asynchronous correspondence and chat room synchronised interaction, indicates several innovations in the field of psychotherapy. Written psychotherapy enhances consciousness, provides full documentation that may serve as scientific data and is accessible to future clients who are unable to apply for face-to-face psychotherapy.
It would appear that online psychotherapy is ready for the natural merging of e-mail therapy and chat-room therapy, in order to create a virtual clinic that will provide clients with a secure frame for online psychotherapy.



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