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VOLUME 1, ISSUE 3 PSYCHNEWS INTERNATIONAL June 1996
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SECTION B: REPORT
VIRTUAL PSYCHOTHERAPY?
Fred Cutter, Ph.D.
fcutter@ix.netcom.com
fcutter@cymbal.aix.calpoly.edu
Does psychotherapy occur on the net? This refers to a licensed
mental health professional exchanging messages with a willing
client on some systematic basis, with or without fees being paid.
It certainly can, and I assumed it did when I started to write
this article. I searched for the topic using available engines
(Alta Vista, Deja News, Info Seek, Magellan, Webcrawler, Yahoo)
and found many "psychotherapy" items on the web, apparently
confirming my expectation.
The citations consisted of text files, professional availability
notices and Cyberpsych. I would describe the latter as meta-
therapy; comments about the behavioral process influenced by the
the net. However, I found very few citations representing
actual psychotherapeutic encounters, or reports by practitioners
of their experiences providing such psychotherapy.
If we use the model of the telephone, which permits a therapist
and a client to have a virtual session, it seems likely that
analogous partners can have an e-mail session whenever they
choose. Because of confidentiality issues alone, these session
should not be visible, and therefore surfers should not find any
references to the sessions. As in the past practioners can write
articles about various aspects of their experiences, and certain-
ly those seeking clients through the web can make that option
known. The examples I found were very low key, requiring great
attention to even find the listing. The latter of course re-
flects professional caution in venturing into a new venue.
In preparation for this article I used six different search
engines, with "psychotherapy"(or counseling) and "net"(or inter-
net, web, cyberspace) as key words. These searches yielded
material that was definitely not psychotherapy. However it was
very relevant and consisted of the following categories.
1) The largest group were text files about psychotherapy much
like those in hard copy journals. Interesting items, very recent,
easily accessed and very useful to practioners of psychotherapy.
2) Less frequent were online lists of mental health profession-
als willing to accept new clients. Most of these described
services in conventional office practice. Many mental health
professionals are listing themselves in their own web pages or in
directories sponsored by various online journals. These are the
early signs of efforts to offer, reach out, and facilitate psy-
chotherapy services, whether in conventional settings or on line
is not specified. I report only that these are occurring with
increasing frequency on a variety of venues. There were very few
that offered to provide services online. I will describe the
exceptions later.
The range of approaches here is quite large. There is a free
psychotherapy referral service in New York City (found in
the newsgroup alt.psychol.help) that sounds very professional in
their presentation much like the Family Service Center in my
locale. Shrink Link described in Suler's web page (see below for
address) offers answers to mental health questions by a panel of
psychologists and one psychiatrist. They charge a prepaid fee
of $20 for each question.
Other groups also offering an answer to a prepaid question are
visible. While this is educational rather than psychotherapy,
there is a pious hope that knowledge changes people, or that the
questioners will eventually find their way into the office prac-
tice of the panel.
3. Buried in items #1 and #2 were subtle references to on line
psychotherapy and counseling. The most explicit was embedded in
the Pink Practice web page (inquire at pinkprac@dircon.co.uk)
based in England and frankly offering services to gays. This was
presented very professionally. They offered e-mail mediated
individual psychotherapy. Their instructions are precedent
setting. I quote
How it works
This works as a correspondence from of counseling
You decide how many consultations you want
You negotiate timing of consultations with the RX
A consultation is a single e-mail exchange
There is no obligation to continue beyond each session
Payment is required in advance of a consultation
Another explicit "web practitioner of psychotherapy" is David
Sommers,Ph.D. (http://nicom.com/~davids/pageone.htm) who provides
a list of four services. Number one is "interactive consultant
and 'psychotherapy'... my way of saying on line psychotherapy via
the internet??" He approaches this venture tentatively, and with
some personal humility befitting a serious professional attempt-
ing something new. He offers the user a matrix of 18 on line
choices which can be visited by clicking on them. One of these is
arranging fees (I understand that he does not charge at this
time).
Another choice is "data and outcomes to date". The numbers for
the month of March 1996 suggest most of his web visitors are
lurkers (N=1050). Of these 35 made e-mail contacts. Those who
had 1 or more sessions were 21. Currently continuing is one.
Twenty of these have had traditional office practice psychothera-
py in their past. The majority of concerns were depression,
followed by anxiety, and a variety of the usual problems in much
smaller numbers.
Sommers goes on to assert that the quality of the relations he
was able to develop with his clients online were equivalent to
that which he enjoys in office practice.
4. Cyberpsych articles tended to cluster on John Suler's web page
(http://www1.rider.edu/~suler/psycyber/psycyber.html). The prem-
ise there is that psychotherapeutic processes are occurring on
line be they individual or group kinds of interaction.
Psychotherapeutic values of online encounters
Suler believes online psychotherapy provides opportunities and
should be studied. He makes the case for four advantages: 1)
online is easier than face to face for some hesitant clients 2)
it may have value as an initial step in forming a face to face
relation 3) it reduces physical or geographical impediments 4) it
permits an instant, total, permanent record of every verbal
message. Others like Greist et al. (1973) have reported that psy-
chiatric patients prefer computerized interviews to live thera-
pists, and reveal more to the machines than to human interview-
ers.
Holland has written an article (which can be found on Suler's
site) called The Internet Regression. He defines this as quick
aggression (flaming), direct sexual expressions, and unusual
generosity all of which are facilitated by Internet process and
contact. This is a thoughtful description of how the user is
influenced by the process of interacting with the terminal it-
self. He reasons that inhibitions are diminished and thoughts
are expressed that would be less likely to occur in a face to
face encounter. There is a comparison to the psychoanalytic con-
text where the analysand reveals far more laying down and not
looking at the analyst. Similarly, he reminds us of the con-
fessional where the penitent reveals more in a dark closet, and
cannot see the priest.
Holland goes on to suggest that one way to understand the process
is to look into the fantasies people have about their computers.
He compares these to the power images projected on automobiles by
men or service values of household appliances by women. Tradi-
tional thinking is that all tools extend physical capabilities,
and the computer extends our intellectual competencies. Along
with personal fantasies comes the feeling that the computer is a
powerful being, and/or has magical forces. Their is also a trend
towards dependency and addiction which is described as an "allur-
ing alternative to life". Not only is it escapist from the nega-
tive experiences with live people, it is seductive in itself for
the sheer pleasures the user can derive. Holland attributes this
to a context of no judgment, nor punishment.
King (http://www.webcom.com/storm/fiction.htm) describes behavior
shaped by the conditions of electronic communications, but having
direct and significant impact on participants, especially in a
psychotherapeutic context. Examples are transference, gender
switching, e-mail relations and suicidal behavior. These articles
are acccesible through King's web page where there are more
specific details.
King confirms the observations by Holland, and supports the
process of users regressing on the net, but also deriving great-
er satisfaction than in comparable real encounters.
These behaviors describe unconscious motives influenced by on
line parameters, that remove face to face visibility, and espe-
cially the expression of body language. Additional factors are
the implicit permission granted by the monitor or television
set. Television folkways over the last 50 years in the USA have
built up an expectation that it never hurts and always provides
the viewer with pleasure in a non-demanding way.
These regressions would be worthy of analysis and working through
of defenses as in the mode of traditional psychotherapeutic
interpretations. And that may well become the ultimate advantage
created by on line psychotherapy, the opportunity to study
individual reactions to the Internet experience, and whatever
subsequent transfer values to real exisitence.
Emotional Support Groups on the Net
Newsnet groups are the most obvious point of departure. Thanks to
John Grohol (http://www.cmhc.com/) and his list of support
groups, we have an easy access to the spontaneous groups that
have formed which offer support to victims of various distress or
disabilities; pain, trauma and mental health topics such as
anxiety, depression, eating disorders to name the most obvious.
Steve Harris (steveha@cix.compulink.co.uk) with the help of
Grohol and others has just published an online list that contains
more than 400 titles oriented towards "emotional support". A full
list is available from several sources.
http://www.compulink.co.uk/~net-services/care/
The file can be downloaded from:
ftp://rtfm.mit.edu/pub/usenet/news.answers/support/
emotional/resources-list
For those without web access the E-mail resources is:
mail-server@rtfm.mit.edu.
Skip the subject and in the body type:
send usenet/news.answers/support/emotional/resources-list
Two years ago I subscribed to a Newsnet discussion list, or
support group called 'walkers in darkness'. They were oriented to
people suffering from depression. I was drowned with postings
equaling a 50kbytes of data per day. I couldn't read through the
items fast enough. I recently subscribed to a fibromyalgia
support group and had a similar experience. Both offered sympa-
thetic support, suggestions for change and a validation of their
syndromes. Family doctors have not been convinced that the com-
plaints presented were physicially based. The doubt conveyed
aggravated the suffering, and online validation was reassuring.
Like any support group participants express positive feelings
about the discussions, or negative reactions to specific state-
ments. The outpourings document a powerful set of needs finding
a place to be heard or seen, yielding support and relief, if not
quite psychotherapeutic progress (insight, change, or growth)
through these Internet groups.
Are these newsnet support groups psychotherapy? It can certainly
be called psychological first aid. At its best it represents an
alternative medicine for those victims of the health care system
who do not get sufficient relief. It is probably not an effective
cure for any psychological syndrome. However, it is a first step
towards making the patient comfortable. Many clients are quite
content with stopping at that point in face to face practice, so
why not the same standard for the Internet? As a starting point,
I can say an enthusiastic, yes. As a treatment standard, I would
assert an equally strong, no. The exception I would make is AA
as a support group which is recognized to be more effective than
standard group or individual psychotherapy. Support groups in
general do not offer what AA, NA, or ACA (adult children of
alcoholic) have provided because these latter approaches are more
focused and have a defined methodology which has passed the test
of time.
Encounters with Internet Relay Chat (IRC)
People seeking immediate contact on the net turn to IRC (Internet
Relay Chat). They are usually not motivated by need for treat-
ment nor cure of an affliction. Instead they seek a human con-
tact, or a need for specific kinds of interaction. The IRC
allows this quest to be fulfilled. It requires typing skills and
the use of abbreviations such as imho (in my humble opionion)
special terms like Newbie. These terms are now used in all
forums. Holland has described some of these as regressions, in
which perpetrators get outrageously angry, sexually more direct
than in actual space, or unusually generous of their time, if not
money. Holland makes a very good case for regarding these be-
haviors as irrational. He reports that there are far more sexual
confrontations in chat groups than reported elsewhere. Suler
reports changing his sex identity (online) and describes the
increase of sexual propositions by others with both male and
female gender type names.
Organizational issues like who is in charge, who could join or
subscribe, and the language of self expression are determined by
the system operator, who has several options one of which is to
"kick" an unwanted user. IRC channels have the advantage of en-
counters in real time although virtual place. Newer software is
making IRC even more accessible, although still not like face to
face group encounters.
I am not aware of any channels devoted to psychotherapy. This
could easily and quickly change overnight.
Role playing in MUDS, MOOs, etc
A different kind of group experience is occurring in what are
known as MUDS, (multi user dungeons) which had their beginnings
in Tolkien's Lord of the Rings books and the Dungeons and Dragons
games of early computers. These evolved from the first version of
mud in 1978, Zork, Empire, & Scepter in 1979, Abermud in 1987,
Tiny Mud 1988, Dragon Mud 1989 and in the 1990s flourished with
terms such as MOO, MUSH, MUCK. Its current version is available
on the WEB and assumes a server on a main frame which coordinates
a data base accessed by a client program on the users personal
computer. More than one user can access a MUD at the same time.
The users make choices which stimulate unpredictable reactions
from the data base, and often influenced by the presence of other
users. These are frankly role playing opportunities designed as
fun, in imaginative settings, not intended to provide support or
to be emotionally cathartic contexts. The early versions were
competitive or warlike, while the later ones are considered world
building or cooperative.
The general plan is for an individual participant to adopt some
role or image and make choices as he or she move from one area
(room) to another. Often there is a goal (find the gold, get the
dragon, or seek a partner). The person who has designed this mud
has a data base of options which are called by the various choic-
es exercised by the player. The designer and owner of each web is
known as the wizard.
While those of us with mental health training recognize the
psychodramatic value of role playing, it is very easy to jump to
conclusions about the needs fulfilled, or the emotions expressed.
While we can infer, and perhaps assign such interpretations to
any one participant, the pre-requisite is familiarity and accul-
turation before one ventures on to play a therapist role.
A personally meaningful re-enactment of roles associated with a
prior traumatic experience tends to be ubiquitous no matter what
the scene. Muds are advertised quite openly as opportunities for
participants to role play any fantasy character of their choice.
Any setting can be chosen, for example a coffee house scene is
the locale for several. These groups are led by very knowledge-
able and competent masters of Internet usage, familiar with
games, and clearly not mental health professionals. There is an
almost phobic like avoidance of "shrinks", countered with a posi-
tive line that the MUD is explicitly fun rather than therapy.
I searched under *mud on http://www.vuw.ac.nz/who/jamie.norrish/
mud/building.html and received several hundred different titles;
each with a two or three line description of what the authors
thought was important to emphasize as an enticement. I did not
see any that listed or implied anything psychotherapeutic or
psychodramatic.
MUDS are efforts to convert fantasy into action. They are prob-
ably an extension of childhood fantasies we derived from the
"movies" of our childhood. After viewing we would go to our homes
and backyards where we and our friends proceeded to role play the
characters and themes we had observed. MUDS are successful at
giving the viewer stimulations and sensations, that feel every
bit as real as the actual encounters, up to the point of consum-
mation. These are essentially offered and taken as diversions,
self-other play.
Clearly, one of the effects is the opportunity to express feel-
ings that might not have adequate catharsis in real life. Absent
a professional goal, supervision, or serious intent, MUDS cannot
be regarded as treatments even though they contain elements of
psychodrama. There is also a potential danger in that their is
bound to be the vulnerable person drawn to these activities who
will be further hurt by what they run into. However, this is no
worse than needy people going to bars, psychics, or self appoint-
ed local gurus. Again it is not professionally supervised group
psychotherapy. Nor is it intended to be such.
Yet, there is a potential for good that is being overlooked.
Role playing may be viewed as adult play therapy, using the model
of toys with non verbal children. There may well be a need for
or value in, creating a mud for psychotherapy with the wizard
being a qualified psychotherapist, and the players seeking a
psychodramatic role-play for selected themes, in the data base.
I see the possibility of MUDS evolving into instant psychodrama
for any one ready to enter these mental health dungeons and slay
the dragons of the mind. If only Moreno (the founder of psycho-
drama) were available to help the wizard accumulate a data base
of roles, themes, and traumas to catharse.
The Future of Psychotherapy on the Net
All technology has a behavioral impact on the folkways of those
who adopt the particular tool. We have witnessed technology
changes that would have startled Jules Verne and the other sci-
ence fiction writers of yesterday; certainly inconceivable to
our parents, and our selves in our youth, or even ten years ago.
All of this says, that we need to suspend judgment about what can
occur and to be more ready to enjoy what is already possible on
the net.
Psychotherapies; such as group, individual, psychodrama or play
therapy are possible on the net. Mental health professionals are
conservative and thus slow to accept most changes until well
established. This article is intended as an over view and intro-
duction to those who are still skeptical. An example of how this
might look in 2005 is provided by Storm King on his web page
(http://www.webcom.com/storm). It is titled: the Internet in ten
years and includes 'counseling on the net'. It really needs to be
read for the full impact, as it tries to convey how people might
access instant online psychotherapy.
Incidentally his story assumes that ordinary people will have
accepted mental health practioners as casually as we now accept a
visit to our family physician, something that all practioners
devotedly hope to see.
Conclusions
1. Aspects of psychotherapeutic behavior are apparent on the net.
These are opportunities to share a pain, seek support, gain
approval or validation for distressing images of self. The locus
of these activities on the net occurs on newsnet support groups,
email facilitated discussion lists focused on a clinical issue,
IRC, and MUDS.
2. These behaviors are evolving like "topsy" and are quite
fragmented when compared to face to face approaches in psycho-
therapy services provided by mental health professionals. It
totally lacks the mutual and therapeutic contract where a li-
censed professional accepts responsibility for the treatment of a
problem presented by a client.
3. Individual psychotherapy is being offered in the various web
pages and online groups. They exhibit a low profile, in which a
potential client is invited to e mail or contact a provider on
the web. Instructions are usually provided on how to do this.
Fee for service is mentioned, but quite often there is no charge.
4. Surfing the domains of the Internet is pleasurable to the
surfer for its own sake, despite sudden but passing frustrations.
Whether the good feeling is due to the regression described by
Holland, or the phenomenon of net addiction, more positive rea-
sons exists (implied in knowledge is power, or the computer is a
better tool). One of these is the case for the advantages of
psychotherapy on the net.
The net surfing process may approximate play, but it is serious
play in the sense of developing new skills, and new domains in
which to exercise them. For us in the practice of some mental
health profession an example might be the feasibility of creating
on line MUDs for Psychodramatic goals or a MUPSYCH using a data
base of traumas, and positive reinforcements. Any wizards out
there who wish to volunteer?
5. The net, and all the surfing it engenders, provides a rich
opportunity for research psychologists to collect data instantly
through automated procedures. Almost any behavioral field of
inquiry is possible. A research attitude is useful in facilitat-
ing psychotherapy. The reverse is also true. There is nothing
incompatible about collecting data for a research goal, and
gathering clinical information to focus on a treatment goal.
6. Virtual psychotherapy, administered online, supervised by
license mental health professionals, is a very real possibility,
which will become more feasible as the current explorations
evolve. Like psychotherapy over the telephone, it occurs now.
There are low profile type of references to its availabaility and
occurrence, although whatever is happening must be viewed as
early explorations.
Documentation will require testimonials by practioners who write
articles about what they have tried. Confidentiality ethics will
always preclude these processes from becoming visible on the net,
or anywhere else.
A science-fiction example of future psychotherapy was written by
Storm King which depicts how a client might seek assistance on
the net. It is accessible through King's web page.
7. In the past writings about face to face group psychotherapy,
it was observed that the collective process added something that
was not present during individual sessions. By analogy, I would
suggest as have others, that the Internet is facilitating the
role of the global village in helping us achieve our higher form
of civilization. Internet psychotherapy will permit a more
efficient use of our time, and more importantly, a more effective
use of our skills in helping people manage their transient dis-
tress.
References
Greist,J, Gustafson, D.H.,Stauss, F., Rowse, M. S.Laughren,T.P.
Chiles, J.A. A computer interview for Suicide-High Risk predic-
tion. Am. J. Psychiatry 130:12. Dec 1973
(John Greist,MD, 1300 Univ. Ave, Madison WI 53706)