The Online Clinical Case Study Group of the
International Society for Mental Health Online is devoted to in-depth
discussions of clinical work that involves the internet. The case studies
include psychotherapy conducted exclusively via the internet (e.g., e-mail,
chat), f2f therapy in which the internet is used for supplemental contact
with the client, f2f therapy in which the client's activity in cyberspace
is an important feature of the treatment, and interventions within online
groups devoted to mental health issues. Listed below is an outline of
the working hypotheses of the group. As the group continues to explore
cases, this list will be revised and expanded according to the clinical
data uncovered by these case studies.
1.The client's experience of text communication
1.1. The psychological meaning clients associate with "writing" will affect
how they experience text communication with the therapist. Clients with
conflicts about writing may prefer chat over e-mail.
1.2. The client's act of writing may in itself be therapeutic by fostering
self-expression, self-reflection, and cognitive restructuring.
1.3 Clients with a history of chaotic relationships may experience text
communication with the therapist as predictable and safe.
1.4 Clients who have been physically traumatized may be attracted to the
silence and non-tactile quality of text communication.
1.5. Text communication may be helpful for clients who experience talking
as a conflicted way to express themselves.
1.6. Some clients may experience text communication as a type of "merging"
with the psyche of the therapist. Issues about separation and individuation
may be important.
1.7. The therapist's e-mail can be a steady, supportive, reality-testing,
ego-building voice "inside" the client's head - a benign internalization
or introject.
1.8. Text communications (e.g., e-mail) can be a steady, ongoing effort
to restructure a client's cognitions.
1.9. By using several sections of quoted text within a single message,
multiple layers of dialogue can simultaneously address multiple therapeutic
issues and multiple layers of the client's personality.
2. Effects of absent f2f cues
2.1. Lacking f2f cues, text communication can be ambiguous and an easy
target for misunderstanding and projection.
2.2. Lacking f2f cues, text communication disinhibits clients, encouraging
them to be more open and honest than usual, or encouraging them to act
out.
2.3. A client's ambivalence about intimacy may be expressed and can be
therapeutically addressed in text communication, which is a paradoxical
blend of allowing people to be honest and feel close, while also maintaining
their distance.
2.4. People struggling with issues about shame or guilt may be drawn to
text-based therapy in which they cannot be "seen."
3. Effects of saved messages
3.1. Saved messages can be accurate data for reviewing the process of
the therapy. They provide continuity and the opportunity for assessing
and assimilating change.
3.2. Quoted text may be cited as "proof" of something someone previously
said, but quoted text can be taken out of context and juxtaposed with
other quoted text as a way to distort its meaning.
3.3. Saving text dialogues with a client can help therapists reduce errors
in recall, some of which might be due to countertransference distortions.
3.4. Saved text read at different points in time will be interpreted differently
based on changes in the client's or therapist's state of mind.
4. Asynchronous communication (e.g., e-mail, message boards)
4.1. The ability to delay responding in e-mail and message boards is useful
in enhancing impulse control, self-reflection, and cognitive assimilation.
4.2. A client's issues about boundaries (separation, individuation) may
be expressed and therapeutically addressed in asynchronous text communication
which provides easy access to the therapist and is not restricted to the
limits of a time-specific "session."
4.3. Some clients may experience the opportunity to send e-mail to the
therapist as a kind of "holding environment." That contact can help clients
with needs for object constancy (even if the therapist does not reply
to the e-mail).
4.4. The therapist can use e-mail to be present "in vivo" with the client
as a way to monitor and guide the client's attempts to understand and
modify their behavior.
5. Synchronous communication (e.g., chat, instant messaging)
5.1. Some clients may benefit from the spontaneity and specific temporal
boundary that is involved in chat sessions.
5.2. Chat sessions create a point-by-point connectedness that enhances
feelings of intimacy, presence, and "arriving together" at insights.
6. The client's expression of identity
6.1. The client's writing style and message format reflects his/her personality.
Changes in style and format reflect changes in mood and thinking.
6.2. Some clients express their "true self" online, or believe they do.
6.3. On the internet, the ability to alter and compartmentalize aspects
of one's identity involves dissociation, which can be detrimental or therapeutic.
6.4. The online name/s and identities that people choose for themselves
reflects their personality dynamics and is a worthy topic for discussion
in psychotherapy.
6.5. Imaginative environments on the internet can be used to do dream
work or to therapeutically explore the client's personal fantasies.
6.6. Because the internet is international, the clinician needs to be
sensitive to multicultural issues and may need to clarify, from the start,
the cultural background of the client.
7. The client's lifestyle in cyberspace
7.1. A client's behavior, identity, and lifestyle in cyberspace (especially
romantic relationships) may express hidden psychological issues. Transference
reactions in those online relationships may be prominent.
7.2. With the therapist's help, clients can use online relationships and
communities as a way to explore their interpersonal style and experiment
with and rehearse new behaviors. What is learned online can be carried
into offline living.
7.3. Role playing in online communities and relationships - including
gender switching - can be a therapeutic way to explore and experiment
with identity.
7.4. Online relationships can be used to systematically desensitize social
anxieties and build social skills.
7.5. Socially anxious people may especially benefit from talking online
with other socially anxious people. Meeting in-person may be an important
developmental step for them.
7.6. Clients can express and explore themselves by sharing what they do
online. A client's online "space" (especially a personal web site) is
an extension of the client's psyche. It is an important therapeutic event
when the clinician or client visits the other's online spaces.
7.7. Clients may experience text from their online relationships as actually
being "pieces" of those relationships.
7.8. Elements of clients' cyberaffairs (especially fantasy elements) may
reveal the problematic aspects of their marriages. Online cyberaffairs
may sometimes enhance a marriage.
7.9. Behavior in cyberspace involves a simultaneous acting and observing
of one's actions. This may be intrapsychically significant to some clients.
7.10. The therapist should encourage and work with the client's empowering
access to online information and transformative experiences.
7.11. Clients may have easy access to numerous online resources and mental
health workers. The clinician needs to assess and work effectively with
a client's online help-seeking behavior.
7.12. As a way to avoid termination, online relationships and groups may
tend to "fizzle out" by people gradually sending fewer and fewer messages.
7.13. Clients with schizoid tendencies may be attracted to the private
"worlds" that can be created on the internet.
8. The relationships between in-person and online therapy
8.1. Online therapeutic interventions can be used as a stepping stone
to f2f therapy.
8.2. Combining f2f contact with online contact of various types offers
the client the ability to therapeutically explore and integrate different
cognitive styles and modes of communication. Different channels of communication
may work best for different people.
8.3. Online support groups can be a valuable adjunct to psychotherapy.
8.4. Some important aspects of a client may be obvious in-person but almost
invisible online.
8.5. Consistently, patiently,and empathically encouraging a client to
seek f2f therapy can itself a form of online therapy.
9. Couples and family work
9.1. Some couples or family members may be able to communicate more effectively
via e-mail or chat than in-person.
9.2. Using e-mail, a couples therapist can become an in vivo presence
and catalyst for change.
9.3. Elements of clients' cyberaffairs (especially fantasy components)
may reveal the problematic aspects of their marriages. Online cyberaffairs
may sometimes enhance a marriage.
10. Working with online groups
10.1. Online groups devoted to information and support regarding mental
health issues benefit from having rules about appropriate behavior, effective
tools to enforce the rules (e.g., the ability to block people from joining
the group), and a knowledgeable and confident leader who has appropriate
technical control over the environment.
10.2. The objectives of the clinician managing an online group and of
the business that owns that environment may not always be compatible.
10.3. The cohesion of many online groups is intrinsically weak due to
the traditional cybercultural assumption that one can join or leave, respond
or not respond, as one wishes. This effect may persist even in small and/or
closed support and therapy groups.
10.4. People who "lurk" in a small online group can become a target of
projection that might disrupt the group. People not even knowing if the
person is consciously present disrupts the boundary of the group and creates
distrust.
10.5. In small online groups, non-responding (lurking) tends to snowball.
When people don't receive a reply, they tend not to post another message.
10.6. In an online group a person may use "multi-tasking" to carry on
several relationships simultaneously - a process that may be dissociative
and counterproductive, or integrative and therapeutic.
10.7. People with dissociative tendencies may act out in online groups
by assuming different identities - some of them antagonistic, some not.
A person may use different identities for the purpose of "splitting" relationships
with others.
11. The therapist's issues
11.1. Some clinicians (and clients) are more sensitive in detecting the
meaning and mood expressed "between the lines" of text communication.
There is a type of empathy unique to online work.
11.2. Because text communication is less efficient than speaking, clinicians
may be tempted to move faster by giving advice or "solving problems."
11.3. If clinicians are active in a variety of online groups and sites,
clients may have easy access to information about them and may coexist
with them in these spaces. Traditional ideas about "therapy boundaries"
may need to be reexplored.
11.4. The equalization of status that tends to occur online may result
in a decreased perception of clinicians as "authorities." The clinician
may be seen more as a consultant who provides information and guidance
in the design of a transformative program. "Twinning" relationships between
the client and therapist may be important.
For other articles about psychotherapy in cyberspace, see the introduction
and table of contents for the section of The Psychology of Cyberspace
entitled "Psychotherapy and Clinical Work in Cyberspace."
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