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
counseling 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
