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A Brief Overview of Technology Mediated Psychotherapy from a Practitioner's Perspective

 

Since the 1980s psychotherapy practitioners have integrated more and more information technology into their work: We regularly telephone clients to arrange sessions, we may record clients for training purposes and we may even have whole supervision sessions via the telephone. Recently, the internet has offered us even more options. We now may arrange sessions with clients via email, consult the web for information we might need and possible use email or internet relay chat (synchronous online communication through 'chat rooms') to stay in contact with colleagues worldwide.

 

The tools involved in technology mediated psychotherapy are the telephone, the internet and computer software. The internet offers a variety of communication channels: Email, an asynchronous (sender and receiver do not have to be online at the same time) text based medium, which can be compared to letter writing; internet relay chat, or 'chatting', which is a form of synchronous (both sender and receiver are online at the same time) text based communication; online video links, which are becoming more feasible as bandwidth increases; and therapeutic software on CD-Roms, which can be seen as interactive, digital self help books.

 

Assuming that it is the connection clients make with the practitioner and with themselves which is at the core of the psychotherapeutic process, any communication technology used in the process can be seen as simply a platform, which enables a connection between two people, just like a face to face meeting does. Technology does not take away from the primacy of the therapeutic relationship, but needs to enable a relationship, even if this relationship has to be based on different cues and communication channels than when both people are present in the same room.

 

From this point of view technology becomes either useful or not useful to psychotherapy. One needs to consider the properties of a given communication channel, as well as the abilities and issues of any specific client-psychotherapist dyad, issues around accessibility, type of therapeutic endeavor, other available options and so forth to judge whether the use of online forms of communication can enable good psychotherapeutic practice.

 

Technology mediated psychotherapy can be conducted in various ways. Online or telephone communication can be used intermittently with face to face contact, for example for clients who travel regularly, but who want to have consistency in their therapy. Online communication might be used as the sole medium at the start of a psychotherapeutic relationship until a client is ready to attend face to face sessions, or as a way of continuing psychotherapy with the same practitioner if a client has moved. Online communication can be used as sole medium, which lends itself to short, solution focused approaches or can be a way of reducing barriers to psychotherapy for clients living in geographical locations without a suitable practitioner or in small communities where dual relationships between clients and practitioner are an issue. Online communication may also be appropriate for clients with mobility problems or disabilities.

 

Practitioners, who would like to consider offering a form of online psychotherapy, training or supervision need to be competent in their work as well as in the specific area of online application of their work. Good introductions to the field are Goss and Anthony (2003), Suler (2004a), and Fenichel et al: 'Myths and Realities of Online Clinical Work'.

 

The internet itself offers many resources on online relationships. One such resource is John Suler's cyberbook 'The Psychology of Cyberspace'. Suler (2003) describes the properties of email interaction and gives an introduction to internet relay chat (Suler 1997). He calls the use of language in emails 'Typed Text Talk' a way of talking through writing, which invites the author into a reflective space more than talking does. An important factor in online communication are the missing face-to-face cues. As a result anonymity is easily accomplished, however, this may also lead to a disinhibition effect (Suler 2004b): The fact that people may disclose more about themselves or behave in ways they would not normally do, because of protection through anonymity. This effect can be used positively in online psychotherapy as clients may find it easier to state their problems and circumventing issues of shame or anxiety.

 

An additional important effect of anonymity in cyberspace is the fact that a therapist may need to find creative ways as to how to ascertain a clients true identity, if the therapist wishes to do so, for example by telephone, mobile phone text, normal mail or credit card payment. If we do not know a clients true identity this may raise issues about protection of the client in a crisis situation as well as about the extend of the responsibility of the therapist to act, for example in cases where criminal acts are disclosed by the client (Suler 2000). Through the absence of face to face cues online communication invites transference readily, which needs to be discussed with the client. Again, this effect could be used to advantage, but may also necessitate careful selection of clients for this type of interaction. Generally speaking, clients will need to be able to tolerate the added ambiguity and ease of misunderstanding, which the medium generates and these issues need to raised by the practitioner at the start of treatment. Client assessment becomes a skill central to technology mediated psychotherapy (Suler 2001).

 

Clear contracting at the start of treatment is essential alongside good client assessment skills. A clear contract as to how the therapeutic work shall proceed can safeguard against difficulties later. Issues which need to be clarified are turn around speed, how quickly the client can expect the therapist to respond, what should be done in case of a technical break down, for example therapist has a telephone number to let the client know that his or her computer or internet access is not functional, and what constitutes 'a session', which the client pays for.

 

Additionally, ethical issues need to be addressed. Is the therapist reasonably certain that the client is able to give informed consent to treatment, (E.g.: How can you ascertain a client's age online?), or that the client is able to withstand the emotional disturbance psychotherapy may bring (E.g. How can you rule out clients, who are suicidal?).

 

Another major issue is around confidentiality. The client needs to be informed about what the limits to confidentiality are as well as that normally he or she is responsible for keeping material, which is on his or her own computer secure. It might be advisable to suggested to clients to protect their written therapy by password or think about whether it is possible for others in their household to access materials accidentally or purposefully and act accordingly. Of course therapists, need to be able to protect data at their end too. The internet creates the added complication that information in transit can not be guaranteed to be confidential. The client needs to be aware of this and options need to be available. Although the probability that someone would access information in transit is limited, probably smaller then someone listening to a therapeutic session at the door of the therapy room, yet the client needs to know of this possibility. For absolute security encryption programs can be used or information can be transmitted without identifiable personal data from an anonymous email account.

 

I would like to raise two more points, which are important for the practitioner when offering online psychotherapy. Firstly, the psychotherapist needs to be familiar and comfortable with using the technological medium. This may seem obvious, but is actually an important point with respect to fluency of use, knowledge of cultural norms in cyberspace and accessibility of technological know-how or back up if things do not work. Secondly, online psychotherapy offers a potentially global space for a therapist to operate in. This means that awareness of cultural difference is important. Client and therapist may come from completely different back grounds as well as different continents. The therapist needs to be able to work with cultural issues and diversity and be open to enquire respectfully into the vast areas of human experience, which he or she may never have experienced him or herself.

 

Technology mediated psychotherapy is a new field in which no agreed standards of best practice exist yet. The International Society for Mental Health Online (ISMHO) is a growing platform for mental health practitioners discussing issues of working online. The ISMHO has published a document suggesting guiding principles for online work (ISMHO 200) and the BACP has published a document on guidelines for online counselling and psychotherapy (BACP, 2nd edition), which gives a concise overview of issues practitioners need to be aware of. One of the major unresolved points about working online is the potential legal implication of practitioners working with a client, who is located in a region the practitioner is not licensed to work in. This is already an issue between states in the US and no clear solution has been found yet.

 

In conclusion, I would like to underline the potential of using technology mediated communication in psychotherapy as an adjunct, support and potentially only channel for delivery of psychotherapy as well as the many potential pitfalls involved. Technology might increase the potential for clients accessing psychotherapy without necessarily diminishing the power of relationship when used well and competently. Finally, although practitioners may not take to technology mediated psychotherapy, clients certainly seem to do: The Samaritans, UK, received and responded to 36,500 emails in 2000 and 72,000 in 2002 (Hanley 2005). How is the profession of psychotherapy going to respond to the demand for mental health services online?

 

References 

BACP Guidelines for Online Counselling and Psychotherapy. 2nd edition

Goss, S., Anthony, K. (2003) Technology in Counselling and Psychotherapy. Palgrave Macmillan

Hanley, T. (2005) personal communication

Fenichel, M., Suler, J., Barak, A., Zelvin, E., Jones, G., Munro, K., Meunier, V., Walker-Schmucker, W. Myths and Realities of Online Clinical Work. Observations on the phenomena of online behaviour, experience and therapeutic relationships. A 3rd-Year Report from ISMHO's Clinical Case Study Group

ISMHO (2000) Suggested Principles for Online Provision of Mental Health Services,

Suler, J. (1997) Psychological Dynamics of Online Synchronous Conversations in Text-Driven Chat Environments. In The Psychology of Cyberspace

Suler, J. (2000) Identity Management in Cyberspace. In The Psychology of Cyberspace

Suler, J. (2001) Assessing a Person's Suitability for online Psychotherapy. In The Psychology of Cyberspace

Suler, J. (2003) E-Mail Communication and Relationships. In The Psychology of Cyberspace

Suler, J. (2004a) Psychotherapy in Cyberspace. In The Psychology of Cyberspace

Suler, J. (2004b) The Online Disinhibition Effect. In The Psychology of Cyberspace
 

 

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