Cybertherapy: Pariah with Promise?

by John A. Ingram, Ph.D.

Cybertherapy? What the (bleep) is that? It is doubtful that you've heard this term before, since it was coined specifically for this article. The term refers to on-line therapy practiced with a qualified, licensed professional with a client, screen to screen, on the Internet. The comments included herein flow from issues raised at the recent seminar entitled "Ethics of On-line Psychology" at the 1996 California Psychological Association Annual Convention in San Diego.

Many psychologists and clients are already "Internet active," and the focal question of this article is whether psychologists want to practice "safe cybertherapy," or do we want to do it at all?

Essentially, the interaction was highly polarized. Mixed reactions are not unexpected because with cybertherapy, we're talking about a sea-change, not psychotherapy-as-we-know-it. As with most revolutions, emotions run high, discussions run long, and substance can run dry. The hope of this article is to provoke some serious consideration and responsible interaction as near the point of cybertherapy's conception as possible.

Cybertherapy as Pariah

The "cons" to doing cybertherapy emerged first, and seem to be astute, valid concerns. The comments on each point are not exhaustive but suggestive.

1. Lack of control. How does the therapist know for certain who is actually on the other end of the interaction unless there has been at least one face-to-face meeting (apparently a requirement in some areas)? The session can be unilaterally terminated, and if the client becomes agitated, the therapist's resources are much more limited.
2. Compromised relationship. With only one (or possibly no) face-to-face contact, the therapeutic alliance is seriously altered, possibly destroyed. At any rate, the interaction style and parameters of relating are so radically changed that it was questioned whether or not cybertherapy is really psychotherapy at all.
3. Loss of metacommunication. Most psychotherapy has traditionally relied heavily on paraverbal material (eye contact, vocal inflection, posture, movement, etc.) which is totally lost in cybertherapy interaction. At least in phone therapy contact, vocal aspects (rate of speech pitch, emotional tone, etc) are retained. How can one accomplish good psychotherapy with these major aspects completely eradicated?
4. "It's not the way we've always done it." It seemed hard for our group to really engage such a radically transformational concept directly applied to our central activity. This question cuts straight to the chase of clear definition of what constitutes (good) psychotherapy, which is still relatively nebulous on a broader scope than just the interface of technology and psychotherapy. Additional questions about on-line practice add more confusion and potential frustration to the picture.
5. Partial anonymity. The client and therapist may find it easier to hide behind another layer of "electronic defenses," thereby making it more difficult to have a truly intimate (particularly emotional) relationship.

Cybertherapy as Promise

Even in light of the significant concerns noted above, some possible "promises for the pariah" also emerged. As these concepts are refracted through readers' minds, we welcome additions to either cons or pros.

1. Flexibility of service delivery. One way cybertherapy was construed was as an additional "avenue" or "portal" for delivery of psychotherapeutic services. For example, it would be possible to start therapy on line with the goal of meeting in person as therapy progresses; alternately, the last few sessions could be done via technical support. Missed sessions due to weather, sickness or even travel of client or therapist might become a thing of the past. On-line maintenance appointments six months to one year later are another possibility. With massive shifts to home businesses, telemarketing, telemedicine, and even tele-mental health already extant in some areas, why should psychotherapy be left out in the cold?
2. Underserved, difficult to access, or otherwise relatively untapped populations. Examples of cybertherapy/Internet advantages include "electronic travel" for rural populations (e.g., northern Minnesota in deep winter), physically handicapped, late stage terminally ill, etc. Additionally, the accelerated geometric expansion of Internet relationships seems to reflect a powerful desire in many for another type of relating in which the parameters are different and therefore desirable. Some who would never face a therapist in her/his office may bare their heart in keyboard dialogue. As a clinical psychologist, part of me loves my therapy and student contact, and part of me loves to "get on-line." What about those who are infinitely more comfortable relating in the on-line format?
3. Potential for providing quality services in a currently uncontrolled setting. One point clearly agreed upon by all is that psychotherapy in some form will be (in fact already is being) done on the Internet. Who could possibly be better than licensed professional psychologists to develop proper guidelines, set standards, and evaluate this new arena for service?
4. Opportunity for cutting edge research. As mentioned above, to the horror of some, and the concern of all, some psychologists are providing fee-for-service cybertherapy already. To offer help from the broader psychological community to these "cybertherapy pioneers" seems reasonable and beneficial to all concerned. We can thus develop initially small sample research data bases, more effectively providing early corrective empirical feedback loops regarding what is efficacious and what is not.
5. Partial Anonymity. Alfred Adler was fond of saying "Your strengths are your weaknesses." Partial Anonymity is listed under both cons and pros because for some potential clients, the lessened threat may lower their threshold for therapy contact, especially initially. First appointments are always one of the most difficult, and an on-line "icebreaker" could be beneficial.

At the 1995 CPA Annual Convention, the tongue-in-cheek title of the computer seminar was "Ask the Nerds," with as many presenters as attendees (about 5 each). This year over 40 attended, for an 800% gain in one year. We must not ignore this exploding market, and figure out how to "Serve the Nerds" as well as any population for which cybertherapy might be more user friendly, accessible, or appropriate.

But it must be done thoughtfully, caringly, responsibly, and scientifically. Why not let the scientist in our scientist-practitioner identity come forward to study this phenomenon objectively rather than armchair catastrophizing?

The above points are admittedly my impression of the feelings and issues represented at the seminar as accurately as I can convey them. This article is not meant to criticize or alienate the holders of either position: rather, to raise the issues for consideration and feedback.

I am indebted to the collective intelligence and hearts of the CPA seminar members as well as Dr. Michelle Weil and Dr. Marlene Maheu for encouraging my role as "cyberscribe" in setting this discussion down in print for your consideration. HELP, all you professional psychologists out in psycho-cyberland -- what do you think?