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Winter 2009/10 | Vol 13 No 2

Myth busters

Exploring the brave new world of online psychotherapy

John Suler

John Suler is a clinical psychologist, whose online book, The Psychology of Cyberspace, is a comprehesive guide to issues in online clinical work. CrossCurrents asked him to discuss what he thinks are the most common myths about clinical work online.

Myth: Online therapy is individual e-mail or chat therapy.
Fact: Although clinical work on the Internet began as one-on-one psychotherapy by means of e-mail and chat programs, it has extended far beyond those communication tools. Today, a wide range of interventions are being conducted online using video-conferencing, group and social networking environments, interactive programs, visual and audio files, and even within virtual worlds such as Second Life, where clients and therapists interact in fabricated graphical environments using visual “avatars” to represent their physical selves.

Myth: Text alone cannot convey the richness of human experience.
Fact: This myth is endorsed by skeptics who believe that the visual and auditory cues provided by clients, such as voice dynamics, facial expression, attire and body language, are absolutely necessary to understand a person’s state of mind. While few people would doubt the importance of these cues, few people would also doubt the power of the written word to express human experience, as clearly evident in the history of literature, poetry and journalism. Entire forms of psychotherapy, such as bibliotherapy, are based on the assumption that writing can be therapeutic. Throughout history, some of the most interpersonally power dialogues between people have been through letters. Why then would we doubt the psychological richness of e-mail or chat?

Of course some people are more expressive writers than others, which might mean they are better candidates for text-based therapy. However, one might argue that the development of writing ability and style are themselves important indices of psychological change. The history of text communication via the Internet also shows us that people are remarkably versatile and creative in finding new ways to express themselves within a seemingly limited communication environment, as evident by the development of emoticons such as the smiley, parenthetical expressions that convey body language or “subvocal” thoughts and feelings (sigh), VOICE ACCENTUATION via the use of capital letters, and trailers ... to indicate a transition in thought or speech. Finally, according to the principle of the online disinhibition effect, people might be more honest, expressive and authentic when communicating via text than they would when facing the clinician eyeball to eyeball.

Myth: Physical presence is necessary for effective therapy.
Fact: This myth overlaps with the one above in that it assumes visual and auditory cures are critical. As I mentioned, visual and auditory presence is possible via video-conferencing and immersion into imaginary graphical/avatar environments. But what about close physical observations of clients or actually interacting with them physically, as in somatic therapies or the simple shaking of hands? Isn’t this close, personal, tactile, kinesthetic, and therefore special aspect of physical human presence lost in cyberspace?

In some respects, yes. However, technologies for transmitting physiological information (e.g., heart rate, blood pressure, galvanic skin response) are already available, and those for sending kinesthetic sensations are developing rapidly (you can now shake someone’s hand via cyberspace!). As for the special personal quality of being physically present with someone, it is important to note that some people feel more real and present in cyberspace than they do in person.

Myth: Effective therapy for serious disorders is not possible online.
Fact: This myth again boils down to the belief that effective therapy requires an in-person encounter. The question is not so much whether online therapy works with serious disorders, but rather, which serious disorders can be treated online, and how. It is not hard to imagine a person with a paranoid disorder or severe social anxiety preferring to converse with a therapist online rather than face-to-face. Nor is it difficult to envision people so psychologically or physically disabled that they cannot leave their place of residence, which makes online therapy a logical choice. Although we might see such Internet-mediated interventions as a first step that eventually leads to in-person work, we should also consider the possibility that online therapy might be the treatment of choice for some serious disorders.

Myth: Offline psychotherapy principles are the same as online therapy principles.
Fact: Many traditional theories about psychotherapy can be translated into online work. However, it would be naïve to think that the medium does not significantly affect the message. Online work calls for a new set of principles – a theory of cybertherapy – that guides us in understanding when, how and for whom the various communication resources of cyberspace are therapeutic. Online clinicians are now searching for principles that reveal what combinations of text, sight, sound, virtual presence, group interactions, imaginary versus realistic environments, and synchronous or asynchronous communication are therapeutic for which people. We are in the process of developing a theory that helps us analyze the potentially curative ingredients of different communication tools and for deciding what environments are therapeutic for which people.

Myth: Any experienced clinician can do online work.
Fact: To be a good online psychotherapist, it is necessary to have good training and experience in traditional psychotherapy, whatever that style of psychotherapy might be. However, this is not sufficient. Online therapy is significantly, and in some cases drastically, different than offline work. Not only does one have to learn the nuts and bolts of Internet communication technology, but also the new principles of online clinical work that are rapidly emerging. Books, journal articles, workshops and training courses are now available for clinicians who wish to venture into the world of online psychotherapy. One excellent resource is psychologist Azy Barak’s online reference list.