Psicoterapia en el ciber espacio

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CYBERPSYCHOLOGY & BEHAVIORVolume 3, Number 2, 2000Mary Ann Liebert, Inc.

Psychotherapy in Cyberspace: A 5-Dimensional Model oOnline and Computer-Mediated Psychotherapy

JOHN R. SULER, Ph.D.

ABSTRACT

This article proposes a dimensional model for conceptualizing the various approaches to co

ducting psychotherapy in cyberspace, including cybertherapy involving the internet, locnetworks, and stand-alone computers. As compared to in-person therapy, computer-mediat

therapy is unique in how it offers the opportunity to interact with clients via different pat

ways, each one having its unique pros and cons, each one involving a different type of re

tionship between client and therapist. The model explores the communication features of fi

dimensions: synchronous/asynchronous, text/sensory, actual/imaginary, automated/interp

sonal, invisible/present. The various dimensional elements can be combined and sequenc

in a variety of ways in order to design a therapeutic encounter that addresses the speci

needs of individual clients.

INTRODUCTION

RELATIONSHIPS IN CYBERSPACE rapidly has be-come a new field of study in psychology.

Within that topic area, we may include thestudy of computer-mediated psychotherapy(i.e., cybertherapy) involving the internet, lo-

cal networks, and stand-alone computers. Clin-icians have already begun to explore methods

for using virtual environments and the internetto help their clients.1 How do these methodscompare to in-person therapy? Although in-person therapy in most cases is preferred, thereare some advantages to computer-mediatedand online interventions. One benefit that ap-plies to all forms of online therapy is the op-portunity to reach people who are unable tovisit psychotherapists for geographical, physi-cal, or lifestyle reasons. Computer-mediated

therapy also may be an important initial stin the establishment of what could become ongoing, in-person treatment. Other adva

tages, as Ill discuss later, are specific to partular types of online therapy. Although I wodiscuss these in depth, some of the biggestumbling blocks to cybertherapy involve legand ethical issues.2

Some people say that in psychotherapy, i

the relationship that heals. If this is true, thmight cyberspace offer different types of thapeutic relationships based on the differetypes of communication it offers? As comparto in-person therapy, online therapy is uniqin how it offers the opportunity to interact wi

clients via different pathways, each one haviits unique pros and cons, each one beingslightly different type of relationship. T

boundaries of time and sensory stimulation c


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be altered. Imaginary environments can be cre-ated. Some or all of the features of the interac-tion can be automated.

In the sections that follow, Ill explore fivefeatures of the communication pathway be-tween therapist and client within a cyberspace

environment:

1. synchronous/asynchronous2. text/sensory3. actual/imaginary4. automated/interpersonal5. invisible/present

Each of these features is not a dichotomy, butrather a bipolar dimension with a gradient be-

tween the two extremes. The five dimensionsalso overlap and interact. Any given style of

communicating can be classified on each of thefive dimensions.

SYNCHRONOUS/ASYNCHRONOUS

Synchronous

Unlike in-person encounters, cyberspace of-fers the choice of meeting in or out of realtime. In synchronous communication, theclient and therapist are sitting down at theircomputer at the same time, interacting witheach other at that moment. Some examples in-

clude text-only and avatar chat, internet tele-phoning, and audio-video conferencing. Tech-nical factors, especially transmission speeds,will determine just how closely a synchronousmeeting approaches the temporal pace of an in-person encounter. In text-only chat, for exam-ple, lag may slow down conversation be-tween the client and therapist, so that there areseconds, or even minutes, between exchanges.

The pros include:

The ability to schedule sessions defined by

a specific, limited period of time. In mostcultures, people understand the bound-

aries implicit in an appointment. A feeling of presence created by beingwith a person in real time (this may serve

Interactions may be more spontaneous, rsulting in more revealing, uncensored dclosures by the client.

Making the effort to be with the person fa specific appointment may be interpretas a sign of commitment and dedicatio

Pauses in the conversation, coming latea session, and no-shows are not lost psychologically significant cues.

The cons include:

The difficulties and inconvenience in haing to schedule a session at a particultime, especially if the client and therapare in very different time zones.

There is less zone for reflection4

(ttime between exchanges to think and com

pose a reply), with the possible exceptiof lag, which offers a small zone for rflection.

In the mind of the client, therapy mbe associated specifically with the apointment and be less perceived as an ogoing, daily process.

Asynchronous

In asynchronous meetings, the therapand client do not have to be sitting at thecomputers at the same time. Usually th

means there is a stretching of the time framin which the interaction occurs. Examples asynchronous encounters include E-manewsgroup or bulletin board postings, and dlayed viewing of audio and audio-vid

recordings.The pros include:

There are no difficulties in having schedule a specific appointment time; dferent time zones are not a problem.

There is the simple convenience of repling when youre ready and able to rep

There is an enhanced zone for reflectiothat allows the therapist and client to thin

and compose a reply. For the client, thmight have important implications for sues concerning impulsivity stimulati

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transference reactions may be managedmore effectively.

The cons include:

The professional boundaries of a specific,

time-limited appointment are lost. Be-cause there arent yet any standards in ourculture about interacting with a profes-sional in an asynchronous time frame, thetherapist must create them in a way thatmakes sense to the client.

There is a reduced feeling of presencebecause the client and therapist are not to-gether in the moment.

Some of the spontaneity of interacting in

the moment is lost, along with whatspontaneous actions can reveal about a

person. There may be some loss of the sense of

commitment that meeting with me rightnow can create.

Pauses in the conversation, coming late toa session, and no-shows are lost as a psy-chologically significant cues (althoughpacing and length of replies in asynchro-

nous communication may serve as cues).

TEXT/SENSORY

Text

A large majority of the interactions occurringon the Internet are typed text. Lacking soundsand images, text conversations are not rich sen-sory encounters. Examples are text-only chat,E-mail, newsgroup/bulletin board forums, andeven web pages that people use to express andexplore themselves with the help of feedbackfrom others (including, perhaps, a therapist).Currently, E-mail is the method most oftenused by psychotherapistsmostly because itseasy to use and rapidly becoming a very pop-

ular method of communicating. More sensory-rich styles of communicating (as in internet

telephoning and audio-visual conferencing) re-quire extra equipment, more technical know-how and fast Internet connections in order to

deed is a visual component to typed text coversationsfor example, in the creative use smileys, spacing, capital letters, punctuatioand ASCII art. Also, the tools for embeddingraphics and sounds into E-mail and bullet

board forums gradually is becoming mo

available. For the most part, however, peopuse typed text.The pros include:

Its easy to serve permanent records some or all of the communications (tefiles are small). Theoretically, a whole pschotherapy could be preserved, word fword. Saved records give the therapist anclient an opportunity to review and ev

uate past encounters. They also could valuable in supervision and research.

The absence of face-to-face cues encouages some people to be more honest anexpressive (the disinhibiting effect).

Some people, due to cognitive or intepersonal style, may naturally exprethemselves better through writing.

Some people who may balk at seeing a thapist in-person (due to anxiety about se

disclosure, the stigma of being a patienetc.) may be more willing to seek text-bashelp due to the anonymity it offers.

The process of writing may tap therape

tic cognitive processes and encourage observing ego, insight, working througand (especially in asynchronous text) ttherapeutic construction of a personal narative, as in journal writing and biblitherapy.

The sometimes ambiguous presentationtyped text can draw out transference ractions (which may be useful to the pschoanalytic therapist).

The cons include:

Due to writing skills, typing skills, ancognitive/interpersonal style, some pe

ple cannot effectively express themselvthrough typed text. The absence of face-to-face cues encou

PSYCHOTHERAPY IN CYBERSPACE 1


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Important face-to-face cues (voice tones,body language, physical appearance) arelost.

For some people the lack of physical pres-ence may reduce the sense of intimacy,trust, and commitment in the therapeutic

relationship. Typed text may feel formaland lacking a supportive, empathic tone. The sometimes ambiguous presentation of

typed text can lead to misunderstandingsand exaggerated projections and transfer-ence reactions.

The identity of the person who sent thetext messages cannot be accurately veri-fied, which raises important confidential-ity issues. People not involved in the ther-

apy also could obtain access to savedmessages.

Even though chat and E-mail are both typedtext, the fact that chat is synchronous and E-mail is asynchronous makes them very differ-ent styles of communicating. As a result, thesignificance of the pros and cons listed abovemay vary for each. For example, the therapeu-tic value of self-reflection, working through, or

writing personal narratives may be much morepowerful in the slower paced E-mail corre-spondence than in on the spot chat. This is agood example of how the interaction of the five

dimensions significantly influence the thera-peutic aspects of a particular communicationpathway.

Sensory

A robust sensory meeting includes sightsand sounds. Audio-visual conferencing in-cludes both, whereas Internet telephoning in-volves only voice. Both methods attempt torecreate the sights and/or sounds of an in-per-son encounter. In this category of sensory com-munication, we may also include the much

more imaginary multimedia experiences. Forexample, in multimedia chat environments,people interact in a visual scene using sounds,

typed text and sometimes voice transmissionto communicate, as well as visual icons calledavatars to represent themselves these are

chotherapeutic implications of such imaginaencounters in the actual/imaginary secti(Note: Sensory communication also could iclude web pages containing graphics, as illutrated by a colleague of mine who interactfor a short period of time with a severe schizo

patient almost exclusively through pictures uloaded to their websites).The pros include:

Multiple sensory cues such as visual apearance, body language, and vocal epression provide valuable information funderstanding the client. Comparing cufrom different sensory pathways can very revealing (e.g., a contrast betwe

what a person says and the body languathat is used).

For some clients, the feeling of the therpists presence may be more powerfwhen multiple sensory cues are availabwhich can enhance the impact of the the

apists interventions, the therapists seobject functions, the sense of intimacy, ancommitment to the therapy

Being less ambiguous than typed text, se

sory encounters will reduce misundestandings, projections, and exaggerattransference reactions

Some people express themselves bettthrough speaking than writing. Speakiis considerably faster and usually conveinformation more quickly.

The cons include:

Sophisticated sensory communication, in audio-video conferencing, requires etra equipment, more technical know hoand fast Internet connections in order work smoothly.

Some clients may be less expressive whconfronted with a face-to-face encountor may feel more uncomfortable with t

many visual/auditory cues. Being less ambiguous than typed text, se

sory encounters reduce the opportunitydraw out revealing projections and tranference reactions

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multimedia chat), or would consume agreat deal of storage space (audio-visualfiles are very large).

IMAGINARY/ACTUAL

Imaginary

When the face-to-face and environmentalcues of the real world fall away, the oppor-tunity for an imaginary world opens up. Cy-berspace is filled with fantasy-based commu-nities, some purely text-driven and somehighly visualsuch as MOOs and MUDs, themultimedia chat communities such as Palaceand many other chat and forum communities

where participants assume imaginary persona.Some people prefer the flight of pure imagina-tion that is activated by text-only fantasy en-

counters. Others like the visual effect of imag-inary graphical surroundings and creativeavatars. Psychotherapists might use this po-tential for imaginary interactions in their work,including not only the creation of their ownimaginary environments for their clients, butalso having clients participate in MOOS,MUDS, or other imaginary communities as anexperiential adjunct to the therapy.

The pros include:

Well-known techniques such as role play-

ing, psychodrama, dream analysis, flood-ing, and implosion could thrive in an imag-inary cyberspace environment. Floodingscenarios could be created or dreams reen-acted by using multimedia tools.

A clients lifestyle experimentation in animaginary online community may providevery valuable material to be discussed inpsychotherapy.

New styles of therapy can evolve out ofimaginary cyberspace tools, for example,avatar therapy in which assumed iden-

tities become a central feature in explo-ration of the clients sense of self.

The cons include:

fense and acting out, a diversion from trpsychotherapeutic work.

Some types of psychopathology may nrespond well to imaginary scenarios, may be exacerbated by it (e.g., psychoconditions).

Sophisticated technology and fast tranmission speeds will be needed for mulmedia environments to mature. (Will timaginary holodeck experiences of StTrekever be possible?)

Actual

A Star Trek holographic experience threcreates all of the sounds, sights, and physicsensations of being there would be the mo

powerful simulation of an actual face-to-fameeting. But were not likely to see this an

time soon. In the meanwhile, audio-visual coferencing is the best Internet technology has offer psychotherapists who want to meclients in an encounter that approximates an iperson encounter. Internet telephoning, whiobviously lacks in-person cues, weighs in atdistant second place and probably has onlyfew advantages over the conventional tephone.

The pros include:

The therapist can very accurately veri

the identity of the client. For some clients, the feeling of the ther

pists presence may be more powerfwhen the therapist appears as a real peson, which can enhance the impact of t

therapists interventions, the therapisself-object functions,3 the sense of inmacy, and commitment to the therapy.

Meetings with the real therapist may rduce misunderstandings, projections, anexaggerated transference reactions.

Some people will feel more comfortable

themselves and can express themselvmore effectively using their own voice an

body language cues.

The cons include:



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cons of having a real therapist present. Theyare obvious. Although computers may be ob-jective and dispassionate in their workal-though they may have better memories and bemore efficient at detecting some changes in theclients words and behaviors and although

some clients may feel more comfortable with acomputerthey are far inferior to the humanin feeling and reasoning about the human con-dition. And thats what psychotherapy is allabout.

INVISIBLE/PRESENT

Invisible

The invisibility of the therapist that comput-ers allow overlaps with the automated/inter-

personal dimension. If psychotherapy is auto-mated, then its possible for human therapiststo oversee the machines work, either continu-ally or periodically. Therapists can adjust theprogram, if necessary, or even step in to in-tervene themselves. If clients believe they areonly talking with a computer, then the thera-pist is essentially invisible. Other variations oftherapist invisibility might include profession-als listening in on another therapists indi-vidual or group sessionfor example, lurk-ing on an e-mail list, perhaps to supervise or

back-up the therapist through private commu-nications, not unlike the bug-in-the-earmethod used in some training programs. Ob-viously, the clients being unaware of the factthat an outsider is listening and/or secretly in-

tervening raises an ethical red flag. With in-formed consent, the invisible professional thendoes become a bit more present for the client.Over time, some clients will forget that there issomeone observing, allowing the professionalto slip more into invisibility. Other clients maynever feel comfortable in what becomes a self-

conscious, even paranoid environment.Its possible for clients to be invisible in the

treatment. They can listen in on individual or

group sessions, either with or without theknowledge of the therapist and other partici-pants resulting in vicarious learning and

The pros include:

Some clients may be comfortable and epressive when they believe a human theapist is not present.

Invisible supervisors could be a valuab

technique in the training psychotherapis Some invisible clients may benefit signicantly from a vicarious learning expeence.

Being an invisible client can reduce eliminate the cultural stigma of beingpsychotherapy patient.

The cons include:

Invisibility of the therapist or client posserious ethical dilemmas.

The curative effects of a healing human rlationship are lost when either the clieor therapist are not present.

The clients or therapists commitment the therapy may be greatly reduced whtheir counterpart is not present.

The idea of being completely invisiblcould lull a therapist or client into a fal

sense of security. With enough technicknow-how, a person can detect others paticipation in any type of Internet meetinThis raises serious confidentiality issu

(as is true for all types of computer-medated therapy).

Present

The pros and cons of the client or therap

being present follow logically from the abodiscussion of invisibility. Psychotherapies threly on a healing human relationship (incluing the development of rapport and trust btween client and therapist) will require a prsent professional. The fascinating aspect computer-mediated therapy is that the degr

of presence can be regulated. in mailing lisand chat, one can mostly or always lurk, or priodically pop in, or maintain an ongoing a

tive participation. The presence of the client therapist will be maximized when the commnication is synchronous and sensory Here an



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son feel more real, alive, and present for mostpeople (some people claim they feel a more di-rect connection to others presence duringtyped text communication). Although the in-terpersonal and present factors overlap con-siderably, it is possible to have an interpersonal

psychotherapy that lacks a present therapist (atherapist pretending to be an automated psy-chotherapy program), as well as an automatedpsychotherapy with a present therapist (psy-chotherapy with a computer program in whichthe client knows that a therapist is silently ob-serving).

DEVELOPING A THEORY OF

CYBERTHERAPY

Psychotherapists from different perspectives

may evaluate these dimensions of cy-bertherapy quite differently. Those who usea specific treatment package that is moreprocedure-oriented than relationship-ori-entedas in some behavioral approachesmay find automated interventions very use-ful. Psychoanalytic and behavioral clinicians

who work with fantasy-based material(dream work, exposure/flooding, implo-sion10 ) or invented role plays may be enticed

by the imaginary dimension of computer-mediated psychotherapists who emphasize

the construction of a personal narrative, as insome psychoanalytic therapies and biblio-therapies.11 Some psychoanalytic workersalso will be intrigued by the heightenedtransference and countertransference that oc-

curs in text-based interactions. On the otherhand, those therapistsespecially humanis-tic thinkerswho uphold the therapeuticpower of a face-to-face, authentic relation-ship may reject any type of computer-medi-ated intervention. They want a fully sensory,present, interpersonal encounter, and the

best that computers offer still pales com-pared to an in-person meeting. Surely, clini-cians who work closely with body cues and

body contact (Thought Field therapies, forexample) will find cyberspace very limiting,

dimension of Internet communication (espcially E-mail) useful as a way to maintacontact with the client.

There are at least three ways to conceptalize computer-mediated psychotherapWe can think of computers as handy tools

be incorporated into pre-existing theories psychotherapy. We can define and develoa variety of new computer-mediated theapies, such as E-mail therapy and chtherapy. We also can conceptualize c

bertherapy as a single, multifaceted style psychotherapeutic interaction that contaithe five dimensional features described ealier, features that can be controlled, com

bined, and modified in a variety of ways

address the needs of different clients as was the changing needs of a particular clien

Each of the dimensions accentuates a certaaspect of psychotherapy. Some of these apects may have been neglected or ovelooked in more traditional forms of clinicwork. In a sense, computer-mediated communication deconstructs psychotherapy (it deconstructs relationships in generanot only revealing its elemental qualities, b

also offering the opportunity to control thoqualities. Most notable is the ability to reglate:

the temporal boundary and pacing of t

therapeutic interaction, including the dgree of spontaneity and the zone for rflection.

how much of the therapeutic encountcan be stored and reviewed.

the visual, auditory, and textual compnents of the interaction, including the rsulting degrees of anonymity, intimacdisinhibition, and transference.

the imaginary and fantasy-driven aspecof the therapeutic encounter.

the degree of human presence and invi

bility, including the power to automasome or all of the therapeutic interactio

There are numerous ways the various dmensional elements can be combined and s

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psychotherapy (e.g., those who are higher func-tioning, educated, and artistically-inclined)may fare well in rich imaginary and fantasy-driven scenarios, coordinated with a text-basedevaluating and processing of the experience.Trauma that needs to be mastered gradually

can begin with text-based explorations, thenslowly incorporating actual sensory recreationsto assist in the assimilation of the trauma. Sometherapies (e.g., EMDR12 ) also may invent imag-inary text and/or sensory resources to coun-teract the trauma. Developing the social skillsneeded to mastering specific difficult interper-sonal situations can progress from imagi-nary/automated/asynchronous scripted roleplays with minimal sensory cues (and perhaps

an invisible therapist to evaluate and coach) tomore challenging spontaneous role plays that

are synchronous, interpersonal, and sensoryenriched. In order to grapple with issues aboutintimacy and interpersonal anxiety, schizoidand socially phobic clients may benefit from atherapy that begins with encounters that aretext-based, asynchronous, and perhaps evenautomatedthen move toward more synchro-nous, sensory, present, and ultimately in-per-

son encounters.Whats interesting about using a term like

cybertherapy is that were defining the ther-apy based on the type of communication path-

way between clients and therapist, and the im-plications of that for technique. Thats a bitdifferent than the more traditional way ofdefining a therapy, which is more closelylinked to ones theory of psychopathology (thecauses of the psychological problem). Its

even possible that our understanding of howdifferent communication pathways affect thetherapeutic process may lead to new frame-works for conceptualizing psychological prob-lems. A client, for example, may be unable toleave an asynchronous, text-based style of in-

teractionin other words, humorously stated,Hes fixated at an E-mail level of interpersonalrelationships. Psychological health may be as-sessed according to the persons ability to moveamong as well as integrate the dimensional el-ements of computer-mediated relationships.

As the technology of cyberspace advancethe methods of computer-mediated pschotherapy will also change. A critical compnent of this change will be a careful evalutionand perhaps reinterpretationof tethical issues associated with the practice

psychotherapy. The foremost concern in tclinicians mind should always be the welfaand rights of the client as outlined by the evlution of professional guidelines.

REFERENCES

1. Wiederhold, B.K., & Wiederhold, M.D. (1998). A

view of virtual reality as a psychotherapeutic tool. C

berPsychology and Behavior, 1:4552.

2. Childress, C. (1999). Potential risks and benefits of line psychotherapeutic interventions. Online do

ment: http://www.ismho.org/issues/9801.htm

3. Kohut, H. (1977). The restoration of the self. New Yo

International Universities Press.

4. Suler, J.R. (1999). The psychology of cyberspace. Onl

document: http://www.rider.edu/users/suler/p

cyber/psycyber.html

5. Greenson, R. (1967). The technique and practice of p

choanalysis. New York: International Universit

Press.

6. Suler, J.R. (1987a). Computer-stimulated psychoth

apy as an aid in teaching clinical psychology. Tea

ing of Psychology, 14:3739.

7. Atwood, G.E., & Stolorow, R.D. (1984). Structures

subjectivity: Explorations in psychoanalytic phenomen

ogy. Hillsdale, NJ: Analytic Press.

8. Rogers, C. (1961). On becoming a person. Bost

Houghton Mifflin.

9. Bandura, A. (1969). Principles of behavior modificati

New York: Holt, Rhinehart, & Winston.

10. Stampfl, T.G., & Levis, D.J. (1973). Implosive thera

Theory and Technique. Morristown, NJ: General Lea

ing Press.11. Spence, D.P. (1982). Narrative and historical tru

Mean ing and interpretation in psychoanalysis . New Yo

W.W. Norton.

12. Shapiro, F. (1995). Eye movement desensitization and

processing. New York: Guilford Press.

Send reprint requests

John Suler, Ph.Department of Psycholog

Rider Universi

Lawrenceville, NJ 086

E-mail: [email protected]



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