VIRTUAL PSYCHOTHERAPY?

                        Fred Cutter, Ph.D.


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

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-

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.

The file can be downloaded from:
For those without  web  access the   E-mail  resources  is:
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

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.


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-


Greist,J,  Gustafson, D.H.,Stauss, F., Rowse, M.  S.Laughren,T.P.
Chiles,  J.A. A computer interview for Suicide-High Risk  predic-
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(John Greist,MD, 1300 Univ. Ave, Madison WI 53706)