EMERGING CLINICAL ISSUES T HEORY IN C YBERSPACE

As has been discussed, the primary concerns regarding online therapy appear to be legal and ethical ones, not clinical ones, but it is the clinical issues in cyberspace that intrigue clinicians, and hopefully, will result in more professional competency online, as well as more equitable access to mental health services for consumers. Current risk management topics do not address whether or not clinicians’ knowledge about cyber psychology and Internet communication is adequate to provide treatment online. Most just assume that if you are a competent clinician in the offi ce, you are competent online (Mallen, 2004). Questions such as How can I best

10 Cyber Shrinks: Expanding the Paradigm

help my patients use the Internet for health purposes? How do I conceptualize and treat a patient’s problematic cyber habit? or How do culture, diversity, and identity manifest online? generate little discourse. At the most reductionist level, do we treat cyber problems online, offl ine, or both?

Diversity and difference defi ne cyberspace communications making gener- alizations and interpretations diffi cult. What is available online makes us laugh and resonate with others. But there is also the other side. Deviance and “the norm” are just a click away from each other. The Internet facilitates global terrorism and live web cam footage of the sexual exploitation of infants as well as other dehumanizing and compulsive behaviors. Who we are online may or may not be representative of our offl ine identities. Much of society, especially our youth, is so inured to media effects that fantasy and fact are synonymous with their perceptions of reality. While mental health providers are required to stay abreast of diversity issues offl ine, no requirements exist for exposing mental health professionals to the growing body of literature about the way we represent ourselves online. Clinicians are often unable to interpret media culture or how this affects on ground behaviors, especially of youth (Taffel, 2005) Some authors propose that clinicians should document self- study in the area of Internet psychology and not practice in cyberspace until there is consensus about what clinicians need to understand about cyber behaviors and cyber treatment. Glueckauf et al. (2003) consider Internet-driven health services a viable option already, especially for the disenfranchised, despite the lack of professional guidelines and practice models. They predict that more clinicians will work online because it provides greater access to underserved populations, increases effi ciency of health delivery, is cost effective, and is driven by a clear grass-roots demand for services.

John Suler, psychologist and author from Rider University, offers a compre- hensive Continuing Education course online entitled Psychotherapy and Clinical Work in Cyberspace. He begins this course with a joke: How many psychologists does it take to do computer-mediated psychotherapy? None, the computer can do it all by itself! (2005, n.p.). Suler (2005) believes that clinicians unfamiliar with online issues are anxious about the future of therapy the old-fashioned way and tend to discount the effi cacy of online therapy. He offers courses on important topics such as analyzing cyberspace as a psychological space, comparing the offl ine and online disinhibition effect, and how to evaluate text as a barometer of mental status, information processing, and interpersonal style.

Derrig-Palumbo and Zeine are also proponents of the online modality. They propose that “many of the cognitive–behavioral theories work best with online therapy” (2005, p. 5). They assert that many approaches such as Imago therapy, Cognitive–Behavioral Therapy (CBT), or Rational Emotive Behavior Therapy “can be easily modifi ed to be conducted online. This concept can ease many therapists’ concerns about preserving their modality and professional identity online” (2005, p. 31). The authors interviewed CBT experts Albert Ellis,

260 Joanie Farley Gillispie

Donald Meichenbaum, Aaron Beck, and others, asking them how they would conduct therapy online. Ellis discussed the ABC’s of Rational Emotive Therapy online with individuals, couples, and adolescents. Ellis believes that online is the “same as face-to face.” Derrig-Palumbo and Zeine’s interview with Meichenbaum provided helpful ideas about using the Web for psycho-educational purposes with depressed or anxious patients, but no discussion ensued about how to help patients screen sites to make sure that the educational information is accurate. Further, the transference dynamic between the clinician and the patient online was explained by Derrig-Palumbo and Zeine as follows:

When sitting in front of a monitor instead of the client, therapists need to be very cautious not to allow their reactions to surface. They may think “I don’t have to hide my feelings because she isn’t watching, nor is she sitting in front of me.” It is important to be fully aware that the same transference and countertransference issues that therapists encounter when face-to-face with their clients may also occur during online therapy (2005, p. 932).

However, others disagree and do not view the online dynamic as the same as face-to-face. Cyber psychology and Internet technology infl uence communication (Lloyd, 2002), identity (Subrahmanyam et al., 2004), disclosure (Suler, 2004), and the therapeutic relationship online (McKenna et al., 2002) in profoundly unique ways. Nickovich et al. (2005) propose that transference issues online are much more complex than a two-way exchange face-to-face because the exchange is continually mediated by the computer. This dynamic is shaped (e.g., channeled, co- constructed, changed, recreated) by the Internet, somewhat akin to the intersubjective experi- ence articulated by Stolorow et al. (1994). In addition, macro- and microlevels of analysis proposed in Heisenberg’s uncertainty principal are also a useful way to conceptualize understanding the dynamic in cyberspace, that is to say, the act of looking at and measuring something changes its form and function.

At the most basic level, when clinicians want to know how to work with patients, psychological theory becomes a heuristic means of transforming what patients say into clinical data that then organize therapeutic intervention strate- gies (McWilliams, 1994, 2004). Mallen (2004) believes that Internet communication has defi nitely reached critical mass, at least enough so that we need to begin to apply the heuristic of psychological theories to its discourse, but suggests that assuming existing theories are adequate or even an accurate way to interpret in cyberspace is misleading and leaves clinicians with “a mixed bag” of therapeutic skills (p. 74). Depending on which research is cited, some investigators are convinced that patients’ face-to-face disclosures are more honest than online ones (Mallen et al., 2003) and thus cannot be clinically interpreted effectively online. Suler, however, proposes just the opposite—that computer-mediated communication is often more uninhibited and contains more honest disclosures of personal information than do face-to-face encounters (Suler, 2004). Does online technology facilitate interpreta- tion in cyberspace more readily way because we are more aware and disinhibited

10 Cyber Shrinks: Expanding the Paradigm

and thus willing to share personal information that is not constrained by the subtle- ties of in person judgments and rules of social hierarchy? The point here is that clinicians must be ready to test their hypotheses about patients online too, just like they do in the offi ce, and not assume etherapy is either good or bad. Unlike face- to-face interactions, text has one clear advantage. It certainly provides a record of conversations however, one where the clinician and the patient can revisit, clarify, and reframe as needed. The cyber problems that affect our patients require prac- titioners to expand and reframe their knowledge. When the interaction is online, clinical skills do not just morph into digital ones.

EMERGING CLINICAL ISSUES T HEORY IN C YBERSPACE