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Psychotherapy and Clinical Work in Cyberspace (introduction and table of contents)

Is it possible to do psychotherapy in cyberspace? That's an important question that I explore in the articles of this section of my online book The Psychology of Cyberspace. Let me begin by telling a joke (and this is one I made up myself): How many psychologists does it take to do computer-mediated psychotherapy?...... None! The computer can do it all by itself!

Now the reason why that joke is (or isn't) funny is important. Maybe, like many jokes, it reveals something we're a bit anxious about. Are computers and the internet taking over our lives? Are human relationships being infiltrated and dehumanized by machines? Will really poor computer-mediated psychotherapy replace the tried and true methods of traditional psychotherapy? We could certainly make those arguments and it's something we should be on the lookout for. On the other hand, computers and the internet do offer many new, enriching forms of human interaction - maybe that includes new and enriching forms of that special kind of human interaction called psychotherapy. On the road to reaching that possibility, we must grapple with some rather complex issues.

First of all, is it ethical to attempt psychotherapy in cyberspace? If the therapist is communicating with the client through typed text (as in e-mail, chat, and message boards), all sorts of valuable information - like physical appearance, body language, and tone of voice - are missing. That easily could pose problems in making an accurate diagnosis and evaluating the treatment, which often rely on f2f behavioral cues. Without f2f cues, the therapist also may not be able to verify the identity of the client. Is the person really who he or she claims to be? Is this particular message really from the client or from someone else pretending to be that client? Confidentiality - an absolutely essential feature of psychotherapy - easily could be violated by this difficulty in validating identity, as well as by the fact that outsiders could listen in on the psychotherapy discussion by intercepting transmissions or gaining access to saved messages. Fortunately, these problems have some viable technical solutions, such as creating secure networks and using encryption and user verification software. Video conferencing, which is an important tool in the TeleHealth movement, also can supply many of those valuable f2f cues that are missing in pure text communication.

Technological solutions don't work as well for the legal and political dilemmas of online clinical work. If a therapist in Kansas is working with a client from Japan in a chat room located on a server in France, where is the therapy taking place? To some onliners, those geographical questions may seem moot because the whole point of the internet is that geographical boundaries disappear. However, the question is not moot for insurance companies and professional regulatory organizations that need to know where the psychotherapy practice is located. To whom the psychotherapist is accountable boils down to a matter of geography. In fact, licenses and certification to conduct psychotherapy almost always are determined by where the clinician practices. Is it legal when a psychologist licensed to practice psychology in New Jersey does online therapy with someone in California, or India? Does the American Psychological Association - the national organization for all professional psychologists - have jurisdiction over the psychologist who works online with that client in India? If the psychologist is making bad mistakes, who will be there to evaluate and correct him?

That last question leads to the issue of training and credentials. Is psychotherapy in cyberspace so different from traditional f2f psychotherapy that it requires special training and certification? From the standpoint of clinical theory and technique, this is an important question. It's possible that clinical work in cyberspace is but an extension or a supplement to the more familiar styles of psychotherapy. Or it's possible that entirely unique theories and techniques will evolve within this new communication medium.

This issue raises one last critical question: What do we mean by "psychotherapy?" Put a bunch of professional psychotherapists together to discuss this matter and you'll be very lucky indeed if they come to any agreement at all, other than a very general definition about psychotherapy being a service in which a professional helps a person with a problem. And that controversy exists even before we mix cyberspace into the debate. Whether we call it "psychotherapy" or not, there have been many ways over the past 100 years to apply psychological principles to helping people. Now, in the new millennium, cyberspace offers even MORE possibilities - many never dreamed of just a few years ago. Because there is easy access to people, information, and activities in cyberspace, some of these clinical possibilities involve an intersection of individual and group psychotherapy, community psychology, and a wide variety of educational and personal growth activities. The articles below explore some of these possibilities. In the future, we may choose not to define these forms of clinical work as "psychotherapy," or we may modify our concepts about what psychotherapy is.


Primary Readings in The Psychology of Cyberspace

Psychotherapy in Cyberspace: A 5-Dimension Model of Online and Computer-mediated Psychotherapy
In this article I propose a "big picture" model of how various forms of psychotherapeutic interventions could be conducted in cyberspace. This overarching "cybertherapy" would be based on the curative features of the different communication pathways that are possible between client and therapist. By combining and sequencing the various features of these pathways, cybertherapy can be designed to match the unique needs of each client.

Report of the ISMHO Online Clinical Case Study Group
One of the groups I created and facilitate, along with my colleague Michael Fenichel, is this case study group of the International Society for Mental Health Online. The group is devoted to in-depth discussions of psychotherapy and clinical cases in which the internet played an important role. This report summarizes the process and outcome for the first year of this group - what we called the "Millennium Group."

Working Hypotheses of the ISMHO Clinical Case Study Group
This document lists the group's hypotheses about psychotherapy and clinical work that involves the internet. Covering a wide range of theoretical ideas and techniques, it serves as the basis for an evolving, practical model to guide our understanding of how and for whom the various forms of online interventions can be applied most effectively.

Avatar Psychotherapy
Avatars are the visual and psychological persona that people use to represent themselves in cyberspace. This article discusses the possibility of an "avatar psychotherapy" in which the client and therapist enact imaginary scenarios with avatars in a virtual environment for the purpose of exploring and altering the various aspects of the client's sense of self.

Computerized Psychotherapy
Can a computer conduct psychotherapy all by itself? In this article I compare the human therapist to the cybershrink, hypothesize about the types of psychotherapy a computer might be able to handle, and describe the results of a project in which my students interacted with the "Eliza" program. The finale is my speculation about the modules that might go into the ultimate computerized psychotherapy program.

Maximizing the Well-Being of Online Groups: The Clinical Psychologist in Virtual Communities
My hands-on work in cyberspace has mostly involved creating, facilitating, and consulting to various online groups and communities. I consider this work to be a type of online clinical/community psychology. In this article I describe the types of situations that come up in this work. I also offer my Top Ten List of issues to consider when working with online groups.

The Bad Boys of Cyberspace: Deviant Behavior in Online Multimedia Communities and Strategies for Managing it
The anonymity of cyberspace unleashes all sorts of misbehavior in people, ranging from inappropriate language to pedophilia. This long article explains the cultural and psychological dimensions of online deviance, catalogs the various types of deviant behavior in a multimedia chat community, and discusses the various automated and interpersonal techniques for managing the misbehavior.


Secondary Readings in The Psychology of Cyberspace

To effectively carry out clinical work that involves the internet, a mental health professional also needs to be familiar with some basic issues in the psychology of cyberspace. Below I've selected some articles from this online book that may be especially helpful in rounding out the clinician's background understanding. Clicking on the bullet will produce a pop-up window with a summary of that article.

Cyberspace as a psychological space
The basic psychological features of cyberspace
The black hole of cyberspace
Identity managment in cyberspace
Personality types in cyberspace
Transference to one's computer and cyberspace
Addiction to computers and cyberspace
Regressive behavior in cyberspace
Integrating online and offline living
In-person versus cyberspace relationships
E-mail communication and relationships
Transference among people online
Cyberspace romances
Therapy and support groups in cyberspace
TextTalk: Communicating with typed text chat
Extending a Work Group into Cyberspace


Ethical guidelines for doing online clinical work have been proposed by a number of organizations:

American Counseling Association (ACA)
Internet Healthcare Coalition (IHC)
National Board of Certified Counselors (NBCC)
Health on the Net Foundation (HON)
American Psychological Association (APA)
International Society for Mental Health Online (ISMHO)

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