E XPANDING THE C LINICAL P ARADIGM [:-C, :-W, (:: () ::)]

[: -C just totally unbelievable; :-W speaking in forked tongue; (:: ( ) ::) offering support]

At this point, becoming expert with online therapy may happen by default. As more of us work online to address traditional barriers to treatment skill in analyzing the interaction among machine, technology, and the human will certainly evolve. Patients who live in rural communities, who have certain phobias, who feel stigma about their condition, or who experience mobility limitations have real diffi culty initiating face-to-face treatment. In addition, fi nding local clinicians or specialists who are approved by insurance providers is especially diffi cult, but now connecting with practitioners online is easy, either for online or offl ine treatment. Often, insurers are receptive to approving

a course of treatment for a diffi cult problem when a clinician’s credentials are easy to access online. An example of a psychologist who helps mental health providers reach those who would not be able to benefi t from treatment is David Lukoff, professor at the Saybrook Institute in San Francisco, California. Lukoff provides training in the online delivery of mental health services to counselors who work with Native peoples in rural Alaska. According to Lukoff, health care providers in Alaska have always recognized the utility of the distance modality because of geographic, fi nancial, and cultural barriers (D. Lukoff, personal communication, Nov. 16, 2005). Lukoff ’s sample treatment website (see Table I) includes direct links to assessment protocols, collateral providers for medication management, educational materials, indigenous support from a university in Connecticut 3,000 miles away, and access to a 12-step program (Lukoff, 2005)

TABLE I Mental Health Internet

Lesson 2.1 A Fisherman in Alaska with a Dual Diagnosis

Treatment Issues

The three cases in Lesson 2 cover a wide range of conditions, including depression, PTSD, substance abuse, medical illnesses, and sleep disorders. They are presented with links to illustrate the range of Internet resources available on clinical topics. This fi rst case concerns rural mental health delivery. It is based on my experience teaching a workshop on the Internet to mental health workers on the Aleutian Islands of Alaska. Many were village-based counselors who had only 36 hours of training and no college education, and yet they provide multiple mental health services ranging from hospice care to detox. Many are now embracing the Internet to fi ll in their gaps in training and

information on assessment and therapy.

10 Cyber Shrinks: Expanding the Paradigm

Case

John is a 29-year-old man living in the rural Alaskan town of King Cove. He works seasonally on the fi shing boats, but when not fi shing, he abuses alcohol. Recently, he has begun using amphetamine as well. He is a dually diagnosed patient. For the past 2 years, he has been taking Zoloft for treatment of Major Depression. He has been referred to the mental health clinic because he has an enlarged liver, presumed to be related to his abuse of alcohol. He states that he doesn’t see the connection between his liver problem and drinking, and doubts that he’s an alcoholic since he doesn’t drink when he’s working on the fi shing boat. He is part Aleutian Indian and has expressed interest in learning more about his Native American background.

Treatment Issues Denial

The fi rst therapeutic objective is to convince John that he does have a serious problem related to alcohol and that his health is being affected by it. An online interactive test would demonstrate to John that he does meet criteria for alcohol dependence.

Internet Resources EXERCISE: Take the Alcohol Screening Test as John, making up responses to fi t someone

who has an alcohol problem (www.health.org)

These are links to pictures from the University of Utah Medical School pathology mini-tutorial on the effects of alcohol on the liver that can be shown to John. Normal Liver Micronodular cirrhosis of liver, gross. This is a brochure on substance abuse from the National Clearinghouse for Alcohol and Drug

Information that can be printed out and given to John. Alcohol: What You Don’t Know Can Harm You

Alcoholics Anonymous

John agrees to get involved with a 12-step program. However, there is no AA meeting currently being held in the small Alaskan village where he lives. However John lives one block from the clinic and is quite willing to come in to use the computer to read the Big Book of Alcoholics Anonymous and to join an online AA group when he is on shore.

Internet Resources Big Book of Alcoholics Anonymous

Below are links to online AA groups About.com > AA Online Meetings > LampLighters

A large e-mail AA Group with over 10,000 members.

Aleutian Roots

John’s recovery could be aided by expanding his social support network for sobriety, including reconnecting with his indigenous roots. In addition to fi nding local resources, an Internet search on the Aleutian Indian Tribe turned up these sites.

Internet Resources University of Connecticut Arctic Circle Web Site

This site contains information on the Aleutian Indians. Four Worlds Institute for Human and Community Development The Four Worlds Institute is an organization whose principles are based on the traditional teach-

ings of North American tribal peoples.

266 Joanie Farley Gillispie

TABLE I (Continued )

Clinical Education Internet Resources

Information on Zoloft is available on several sites, as you’ll learn in lesson 4. Here is the information from the Internet Mental Health Site: Zoloft (Sertraline) Dual Diagnosis patients present unique treatment challenges. Visit Kathleen Sciacca’s Dual Diagnosis Website: Mental Illness, Drug Addiction and Alcoholism.

RESOURCE KEY:

Audio Website Document Quiz

As comprehensive and clinically appropriate as the example given is, clinicians still express concern about adequacy of the online modality to motivate patients to participate fully in treatment. A recent study of online therapy found that the

electronic form of therapeutic communication resulted in higher levels of participation than did traditional offl ine methods of therapy. Day and Schneider (2002) conducted an experiment comparing distance versus face–to-face therapy. Their fi ndings suggest that patients tried harder and participated more because of the distance model. The authors surmised that the text-based, time-delayed technology required more effort in transposing thought to text. In addition, the privacy and anonymity online appeared to encourage high levels of disclosure with this group of patients. The data to date tells us that online treatment appears to increase patient motivation and treatment compliance, which may in turn change the fact that one-third of new patients offl ine drop out within the fi rst three sessions (Lober & Satow, 1975).

Informal case consultation may also begin to change the clinical landscape as clinicians begin to treat more and more patients who present with a cyber issue and they themselves begin to use the Internet as a communication tool in their practices. They ask questions like do you practice online? Or what’s the Standard of Care in cyber space? They want to know when the Internet is appropriate for patient services? For example, as education is such an essential part of therapy, patients may come to expect referrals to web-based National, International, or major research organizations for information about diagnosis, medication, or adjunct treatment. Further, patients need to know the empirical data if it is germaine to their health issue. There are now established and effective online treatment protocols for many mental health disorders (panic disorder and cancer support among others) that could have great benefi t to patients either as an adjunct to face-to-face therapy or as collateral treatment.

The vignettes below are examples of realistic clinical scenarios that any mental health practitioner may encounter in his or her offi ce but for which there are no treatment protocols. Discussing the online and offl ine legal, ethical, and treat-

10 Cyber Shrinks: Expanding the Paradigm

ment considerations with colleagues begins the process of increasing our facility with online clinical and professional issues. How would you eframing the following psychological interventions?

What kinds of patients would you consider using a hybrid (online/ offl ine) model of treatment?

Would you feel competent providing therapy for a couple because one partner is having a cyber affair?

A colleague wants you to review her website for clarity and professional- ism. You are uncomfortable with the marketing strategies used and the direct links to purchasing her books and tapes. Is this unethical, unprofes- sional, or a legitimate way to grow your practice?

Should you refer a patient to an online 12-step program?

What do you say when a 14 year-old patient tells you that she receives hate mail from classmates via Instant Messaging.

What would you say to a colleague calls you for a consultation regarding an adult patient who regularly chats with teenagers on MySpace to give them “a supportive ear.”

How would you conceptualize the treatment for a patient who admits to being addicted to cyber porn?

Do you continue therapy with a patient who has moved to another state via email and telephone?

How would you advise a colleague who conducts therapy using an online and offl ine system of treatment despite the fact that their liability insurer has attached a rider to their policy excluding Internet-based practice because there are no professional standards or laws enforceable in cyber space?

Thinking deeply about our patients is what we do. When there is a cyber component it is incumbent upon us to conceptualize treatment in new ways. Online practice issues provide us with an opportunity to challenge our on ground mind-sets. Cyber problems that patients bring to us like affairs, harassment, and compulsions are certainly treatable but may be especially diffi cult to contain within cyberspace. Problems may have offl ine or online components, or both which may require different case formulations and thus different interventions. For example, a cyber affair may

be an adaptive way to explore a different sexual identity or begin to acknowledge what is missing in one’s current relationship. In contrast, a cyber affair may be a part of a cycle of impulsivity that will escalate and be eventually acted out offl ine.

Because interactions in cyberspace are less inhibited in both positive and negative ways, clinicians must decide if problem cyber behaviors are even treatable using their existing repertoires of knowledge and skills. Can a patient’s Internet behavior be analyzed or diagnosed as healthy fantasy projected into the collec- tive unconscious of cyber space and thus provide both fi gure and ground? Are doing things on line that you would not do offl ine cathartic, a release of socially

268 Joanie Farley Gillispie

constrained angst, a safe and creative form of expression, meaning, and personal growth? Or, are one’s cyber habits, if repeated often enough, eventually going to leak offl ine, especially as Internet technologies involve our physiological responses (Haptics) as well as portable, imbedded, and 3-D screens allow us to feel inserted into the screen? Time will tell. As behavioral and mental health clinicians we are in

a good position to assist our profession, the public and our patients in understand- ing communication, identity, and relational issues in the digital age what healthy online behavior looks like but only if we do not merely upload theory and practice to cyber space. What’s a practitioner to do? We wonder which should be treated fi rst–the online issues or the offl ine effects of cyber problems? The rubric for treat- ing a harmful cyber behavior could be abstinence, immersion, in vivo exposure, or involve harm reduction strategies or a combination of all of these. In other words, professionals who work in cyberspace or who treat cyber problems will still need to assess, consult, try different treatment strategies, and continually analyze the dynamic of cyborg. Clearly online is not the same as offl ine. The horizontal power structure and multiple selves that defi ne cyber culture and cyber psychology move us beyond transference and counter transference into an intersubjective double helix of possibilities. Even if we are not online ourselves professionally, more and more of our patients will have an online issue that needs our help It is only a mat- ter of time that the digital age will require that we are much more informed about cyber culture than is currently the case.

The Internet has given us an opportunity as health communicators to exam- ine the limitations of our personal and professional assumptions. Fortunately, this paradigm shift forces us and our profession to be more effective in the ways we have needed to be all along: making psychology more accessible to those who need it and creating more meaningful discourse around the topics of diversity.

If we choose to work online or not, we still live offl ine. Let’s hope that the thrill, the realities, and unknowns of cyberspace interactions will transform the sys- tems of psychology that needed a good overhaul while at the same time preserving, extending, and enhancing the value that our profession brings to our connections with each other.

Haraway’s Cyborg Manifesto is a philosophy that can be applied to expanding the paradigm for clinicians.

Now we are all hybrids of machine and organism [there is] pleasure in the confusion of boundaries…urging us towards a greater unity…holding incompatible things together because both or all are necessary and true …

Embracing the skillful task for reconstructing the boundaries of daily life, in partial connection with others, in communication with all of our parts … Cyborg imagery can suggest a way out of the maze of dualisms in which we have explained our bodies and our tools to ourselves. It means both building and destroying machines, identities, categories, relationships, space stories. Though both are bound in the spiral dance, I would rather be

a cyborg than a goddess (1991, pp. 30–31).

10 Cyber Shrinks: Expanding the Paradigm

Let’s analyze the spiral dance of the cyborg together and move towards more respectful, joyful, authentic, and sustainable ways to live in harmony. (411^_^), :-)? Translation: Japanese emoticon and net lingo acronym for Got the informa-

tion on that?) (“Smileys and Emoticons for E-mail and IM,” 2005).

E XPANDING THE C LINICAL P ARADIGM [:-C, :-W, (:: () ::)]