The Electronic Couch
Does group therapy mean sitting in a room with other people? Not necessarily, not anymore. Across the country, among the geographically isolated or the merely overscheduled, online groups are gaining in popularity.
One threat to conventional psychotherapy noted in a recent New York magazine story is the fact that people are seeking solace from strangers on the Internet. Most of these interactions have so far been casual, in AOL chat rooms or special-interest bulletin boards, but researchers, hopeful about the community-building potential of online interactions, are exploring the possibilities of electronic therapy. A few therapists already allow online sessions as substitutes for in-person sessions, the way a phone call now occasionally fills in. Others are experimenting with charging online--usually a dollar a minute for typing responses to clients' questions, low compared to the $100 50-minute hour.
In the world of online psychotherapy, Yvette Colon, a bilingual social worker who coordinates online services for Cancer Care Inc., is a pioneer. She found her way to cyberspace 13 years ago when, being treated for ovarian cancer, she went online to research her condition. At the time she found little to keep her involved, but nine years later, experienced in conducting both individual and group therapy, she joined the Echo community, and was invited to form therapy groups there. A candidate for a Ph.D. in clinical social work, Colon is now writing her dissertation on online therapy groups. Her no-fee experiments on Echo were designed to test her hypothesis that "Face-to-face and online [group] therapy are not profoundly different."
Three years into her research, Colon believes her initial hunch was accurate. She still prefers to do individual therapy in person; in sussing out an individual, body language is key. "Online is harder, because I have to listen more. I don't have body language, inflection, or tone of voice. I just have text."
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For group therapy, however, the advantage of the online environment is, ironically, that it stretches the time between a comment and a response. "If something comes up online--a question, aggression, disagreement--I can step back and respond more appropriately, take longer to really think or consult with a colleague about a better clinical intervention."
In assembling her Echo groups, Colon chose only applicants she didn't already know ("I don't do therapy with my friends," she asserts), and never met the group members, whom she selected after they e-mailed answers to a screening questionnaire. Those chosen agreed to participate for three months (later extended, "because no one wanted to stop").
Colon's Echo groups used the Caucus software, which stores responses so each group member can check back over everything that everyone's said (they tried "chat" formats but found them unwieldy). Responses are organized into items; each participant had an item for his or her particular issues, which the others could read and respond in, and then there were items for general discussion, on such subjects as group process, dealing with conflict, dealing with anxiety, and problems with other family members. There was also a space reserved for "venting," where members could simply record their frustrations.
"People think the online world is different from the face-to-face world," Colon says. "But on the other end of the computer is a person. People can use the medium to isolate themselves, or to avoid social contact, but it's really about people talking to each other in a different way, about building a sense of community in a high-tech world."
Participants agreed to post at least three times a week, but most logged in to the secure online space every day. "My role," says Colon, "was to read, respond, and interpret. Doing it online also involves listening. Conflicts in the group were very similar to what happens in a face-to-face group. You can tell when people are yelling at each other, ignoring each other, being ambivalent about an issue, feeling sad; all that stuff comes through."
Self-disclosure, she observes, is more intense and comes more quickly online, because people are not looking at each other or being looked at, and because they can explore their issues at their own convenience, instead of having to wait for the next group meeting. Some members complained that she seemed remote (because they couldn't see her), but her time commitment is actually larger than usual, because she feels obligated to read posts at least once a day.
Other participants actually preferred the online adventure to conventional groups. "In f2f you own nothing, you build on nothing," says one group member (responding, of course, to an online query). "You forget what you just said when you defer to the next person interrupting, demanding their time slice. F2f is more like a flirt palace. Or a waiting room. Or a Billy Crystal act."
Another member writes, "I liked being able to go in to the conference at any hour to post what was on my mind. It felt very safe. However, I remember being frustrated because a couple of other people were unwilling to open up as deeply to the group or participate as actively. Because they weren't there physically, I guess they didn't feel as much investment in the group as I did."
Though mainly enthusiastic about the new therapeutic medium, Colon is concerned about the people it excludes. Most American online interactions are conducted in English, as are her groups. Participants need a computer and access to the Internet, an expensive proposition for those on limited incomes. They've got to be able to type, be text-oriented, and manage to arrange a peaceful space with no interruptions to ensure concentration equivalent to what they'd get by meeting in a shrink's office.
But beyond these obvious differences, the same dynamics come into play as in face-to-face therapy groups. Resistance manifests itself. "Men tended to be quieter, to joke more, to make light of things instead of really going deeper. They didn't post in the same degree or to the same depth." Colon notes that racial and ethnic differences have less impact in online environments, and that the technology makes it possible to assemble people based in different regions.
Confidentiality is still a concern; though online interchanges can be password-protected and even encrypted, they're still vulnerable to hackers or merely to acquaintances wandering through a room. And old assumptions about face-to-face contact between patient and therapist die hard. "If you do it online," Colon asks, "can you call it psychotherapy? How do you deal with a a suicidal person online? Is that ethically responsible?"
For the less troubled participant, the structure of online communication contributes to the group environment: there's plenty of time to pay attention to others. "There were people who'd produce long and thoughtful posts consistently," recalls Colon. "I thought it was amazing, the level of thought that went into getting their ideas across, and giving feedback in a caring way."
The downside? Quiet people are for all practical purposes missing in action; when you can't see them, you can't invite them in with a question or a glance. And, says Colon, "when I type now, I wear a brace, because I don't want to get carpal tunnel problems."
Colon (firstname.lastname@example.org) plans to assemble a new online group late in 1997.
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