INTERNET SUPPORT GROUPS AND TEXT-BASED GROUP THERAPY

INTERNET SUPPORT GROUPS AND TEXT-BASED GROUP THERAPY

Hundreds of mental health professionals worldwide are now offering to establish a therapeutic relationship over the Internet by use of e-mail exchanges and/or real-time chat rooms, most often for a fee. A survey of 136 websites offering some form of Internet therapy, usually for a fee, revealed that fully one-third of the sites were hosted by someone who had no mental health-related degree or license (Heinline et al., 2003). There is no governing body that can monitor the quality of care provided online or the competency of the professionals providing treatment. “A poorly informed consumer in crisis who has a history of mental health diffi cul- ties will be an easy target for incompetent or fraudulent Internet counseling service providers” (Sampson et al., 1997).

Internet support groups can be thought of as professionally assisted text- based mutual aid. Facilitated group therapy online is very rare, compared to the number of people that use the open, unmoderated Internet self-help groups. These text-only support group environments represent an underused resource that can be potentially very therapeutic to appropriate clients. In a small, closed, and moder- ated online support group, the therapeutic advantages of text-based relationships outweigh the disadvantages. These online groups can be organized and moderated by mental health professionals as an adjunct to f 2f therapy with clients, and as a

238 Storm A. King and Danielle Moreggi

method of last resort for someone in need who is unwilling or unable to present for f2f treatment.

There are unique legal and moral obligations a therapist has to clients that he/she treats in an Internet support group. Part of that obligation can be accom- modated by extensive initial screening for the appropriateness of the client to this type of intervention. It is very important to solicit fully informed consent prior to treatment. There is an obligation to inform potential clients about the advantages as well as the disadvantages of text-only relationships. Other ethical, legal, and moral imperatives remain but are less defi ned; for example, it is not clear how a licensed mental health worker can provide online services to people from other states and other countries, when their license to practice is most often restricted to one state.

The occurrence of this type of text-based group therapy, and its obvious advantages to some, is spurring regulatory bodies to attempt to accommodate the new communication technologies. Until more empirical data on Internet group therapy is available, therapists need to proceed slowly and assist one another in evaluating their groups to ensure that clients are receiving quality care. The use of e-mail by therapists to consult with each other, and other mental health profes- sionals, is a growing practice. Research results from studies of the value of Internet therapy can guide professionals involved in creating and leading text-based mutual- aid support groups.

Several organizations have developed guidelines for Internet therapy. Many of these guidelines apply to the situation faced by a professional leading an Internet support group. The National Board for Certifi ed Counselors, Inc. (NBCC) has developed a set of standards for the ethical practice of what they call WebCounseling. The standards include this one: “WebCounselors need to mention on their websites those problems they believe to be inappropriate for WebCounseling. While no conclusive research has been conducted to date, those topics might include sex- ual abuse as a primary issue, violent relationships, eating disorders, and psychiatric

disorders that involve distortions of reality.” The International Society for Mental Health Online was formed in 1997 to promote the understanding, use, and development of online information and technology for the international mental health community. One of the goals of this organization is to explore and develop the use of computer-assisted communica- tion in the work of mental health. The ISMHO website provides an excellent set of ethical guidelines for working with clients in text-based environments. One guideline that applies to Internet support groups read as follows:

Another issue specifi c to online mental health services is that the counselor can be a great distance from the client. This may limit the counselor’s ability to respond to an emergency. The counselor should therefore in these cases obtain the name and telephone number of a qualifi ed local (mental) health care provider (who preferably already knows the client, such as his or her primary care physician).

9 Internet Self-Help and Support Groups

One of the advantages of text-based relationships is the ease and conve- nience of access. By providing a text-based therapeutic environment on an e-mail discussion list, both the clients and the therapist have the ability to schedule their participation at their optimal time. One factor that limits interpersonal close- ness on the large, open self-help online groups is the lack of boundaries. Such open forms are loosely organized and members frequently come and go with- out notice to others involved. An online support group has boundaries set in advance, in terms of the number of members and the time commitment required to participate. The moderation of the group prevents the kind of argumentative fl ame wars that can disrupt open online self-help groups. When the therapist has the ability as a moderator to approve every message before it is posted to the group, they can ask members to reconsider a potentially disruptive message. This is a capacity not possible with f2f groups.

There is also nothing preventing group members from sending each other private e-mail. Members could be encouraged to bring such “backchannel” rela- tionships to the group process. There is no equivalent to this capacity in f2f groups. It would be similar to two group members whispering to each other, a disruptive event in a f2f group. In the online group, any member can send private messages to any other member. The ability of the facilitator to also have concurrent private conversations with individual members is a unique advantage of Internet support groups.

There is an alternative to both Internet self-help groups and Internet support groups. An open unmoderated “self-help” group that is hosted by a trained mental health professional has many of the advantages of Internet mutual-aid groups with fewer of the disadvantages. The host can act as an administrator and as a supportive infl uence in the group discussions. A group of this type was hosted by Dr. Hsiung, who published a report with the explanatory title The best of both worlds: An online self-help group hosted by a mental health professional (Hsiung, 2000). Rather than lead- ing the group as in the f2f model of group therapy, the host focused on how to “empower the helpers in the group” (p. 947). The group is not moderated, but the host did at least scan every message as it was posted. The host reserved the right to prevent someone from further posting if they ignored the rule to “Please be civil, even when provoked” (p. 943).