Online Therapy: Clinical and Ethical Issues

ONLINE THERAPY: CLINICAL AND ETHICAL ISSUES

Interview #1: “Overview”

MICHAEL FREENY, LCSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Michael Freeny, LCSW 430 Crown Oak Center Longwood, FL 32750 407-830-0026 E-mail: [email protected] Website: www.terminalconsent.com

Welcome to On Good Authority. I‟m Barbara Alexander. You are listening to reading Interview #1 in our program about Online Therapy.

Even though it has only been with us for a decade or so, the Internet has changed our lives forever. Once dismissed as a toy for teens and lonely hearts, the Internet, to quote one of our speakers, Dr. Kerry Sulkowicz, “has already so infused our culture that it has become a metaphor for much that is fast, new, exciting, progressive, even dangerous in our society.”

Thus, the subject of online therapy brings into high relief the age -old controversy between the new and the old, the tried and true vs. the innovative, risk vs. safety. Over and over we hear again the phrases we used to hear our parents and grandparents say. Here‟s a great oldie–“Just because everyone else is doing it, that doesn‟t mean You should!” and comments along the lines of “What is this world coming to?” followed by shaking of the heads.

Is seeing a therapist online an oxymoron? Though the idea of “seeing” a therapist online doesn‟t make immediate sense, e-therapy is most definitely finding its market. Here are a few statistics:

The Concerned Counseling website, which provides a variety of services to individual and EAP clients, strictly via email, gets about 200,000 hits a month on its website.

In a survey of 326 people in England conducted by the Maudsley Hospital and Institute of Psychiatry in London in 2000, 27% of those surveyed indicate that they‟d actually prefer to receive behavioral services over the Net than go to see a provider in person.

The where2listen.com website reports that more than 10,000 people sought counseling with their therapists since April 2000 and Feb 2001.

Our first speaker, Michael Freeny, among others reports that in 2000, more than 60,000 online therapy sessions occurred over the Internet, with clients and therapists linked by computers and video. That doesn‟t include hundreds of therapists who offered clients private online chat or e-mail sessions.

According to a PCData, Gomez, and CyberDialogue, currently, 21.8% of doctors exchange emails with patients 70% of patients would like to exchange email with their doctors. (If you‟ve ever played “telephone tag” with your physician, you will have great empathy with this.) 33.2 million adults have visited their doctors‟ websites on line 33.4 million would do that if their doctors had sites and 14-8 million are likely to switch doctors in order to see one who has a site.

According to Time magazine, 64% of those who have their first contact with a therapist online eventually move on to consult one in person.

And the numbers grow daily.

Does this mean we should leap onto the bandwagon? Ride the wave of the future? Just because many are doing this, is it ethical? If ethical, is it effective? As you can imagine, the mental health professions are wrestling with these issues and folks are taking sides.

What do we need to know in order to begin making a decision? For me the first thing is to start at the basics–I mean, how does it actually work?

In this program we‟ll give you an overview of the mechanics, the legalities, the ethical issues, the treatment modalities that seem to be best suited–although the data won‟t be in for years–and try to answer everything you ever wanted to know and never even thought of before!

Our first speaker is Michael Freeny, LCSW. He is an author, clinician, and consultant living near Orlando, FL. In this interview, he offers a lively and humorous look at the range of clinical uses–and misuses–of the Internet. Listeners will learn how to find resources for themselves and their clients on the Web and how they can plug into this new medium.

Mr. Freeny specializes in developing strategies to help health care professionals effectively integrate information technology tools into their practices. In addition to his clinical practice, Mr. Freeny is an expert in information technology and uses his understanding of human nature and

2 computers to provide insightful and entertaining presentations about the juncture of man and machine. His “Love and Sex” chats at yahoo.com rank in the top ten nationally. His novel, Terminal Consent, has received the highest acclaim for dramatically and accurately describing the challenges of modern healthcare. He is also the author of numerous articles in both professional journals and the popular press as an advocate of medical privacy and quality care.

ALEXANDER: Mr. Freeny, can you define online therapy?

FREENY: It‟s therapy that is online. (Laughter) That‟s the simple answer. There are a variety of ways and modalities for conducting therapy online. The simplest form is email. A client will email the therapist a question or a concern, and the therapist will in their time email them back.

Then we have chats, and chats are where you log on, and there are text screens at both ends of the connection. Chats are very popular at AOL and Yahoo, particularly celebrity chats and expert chats, etc. I do a “Love and Sex” chat and in a big “Love and Sex” chat, there could be up to 3,000 people in there asking questions. But in the therapeutic milieu, usually you have just two people logging into a chat server such as Yahoo, and those chats can be made very private and very secure. So the entire exchange occurs between the people in real time just with text characters on screen.

ALEXANDER: Is that the same as instant messaging?

FREENY: Well instant messaging is another way to get text from one point to the other. That‟s where you pop up the instant messenger either at AOL or there are a couple of others, and you send a specific message to a specific person, so it‟s a little like instant email. In a chat, the text stays on the screen; in instant messaging, the text goes away as one message follows another, so it‟s similar to instant emailing.

There‟s also voice chatting where you can actually hear voices over the internet much like a telephone, although there are some little delays in that.

Then finally there is streaming audio video where there‟s a moving picture, you‟ve seen those little ball cameras that sit on the top of a computer. They put out a reasonable image and as the speed of the internet increases, it will seem more and more like television. You basically talk while looking at the person on the screen and they‟re looking at you.

ALEXANDER: Their faces?

FREENY: Yes. It‟s like video phones if you will, or you can look at anything else they want to show in the camera. For example, if they want to show you a picture of their husband or anything like that, they can do that.

Those are the fundamental ways in which client and therapist can interact in online therapy.

What‟s really fascinating is each one has their own purpose and advantages and disadvantages. Now most therapists consider face to face therapy in the office to be the Cadillac of therapies. It turns out--because of the stigma and embarrassment and mystery of mental health--we know of millions of people who could benefit from mental health services but never actually access it for fear that they‟re going to walk in and have to face someone and tell them their problems. They worry that this “authority” might deem them to be crazy or say that they have abnormal feelings or whatever. So a lot of people flatly would never consider going to a therapist--of putting their toe in the therapeutic water--for fear they would be criticized or made to feel uncomfortable. This is what we are terming “the tyranny” of face-to-face.

Another issue with face-to-face therapy is it‟s highly interactive, or what we call “synchronous.” The two parties are speaking, interaction is ongoing and there‟s a clock ticking. There‟s only some much time you‟re going to have and there‟s social pressure to keep the conversation going.

In what we call the A-synchronous modes--for example email--the therapist can ask a question and it will arrive at the client‟s mailbox. This client can read it at his or her leisure, think about it for a while, reflect upon it and sort of really chew on it. When they‟re ready, they email a response back to the therapist who will then consider that and it just sort of goes back and forth. It turns out that a lot of people like to begin therapy that way. In fact, one study found that 64 percent of the people who try online therapy have never and probably would have never tried face-to-face therapy first.

ALEXANDER: Why would we as therapists want to do online therapy?

FREENY: Well online therapy, like telephone therapy, is a growing tradition and it‟s just part of an arsenal. Online therapy can either be a supplement to therapy, and adjunct, or it can be the whole process. There are therapists like myself and many others who have done all three. My clients have been emailing me for some time…

ALEXANDER: Your face-to-face clients?

FREENY: Yes, my face-to-face clients. Sometimes they have questions, sometimes they need resources, and sometimes it‟s just to schedule an appointment. It can be very convenient, as long as the clients know the limitations of email (we‟ll get into the privacy and timing concerns in a few minutes).

For example, there‟s a very famous client who has been very open and has been interviewed a lot, named Martha Ainsworth, who had some regular face-to-face therapy but found it was very difficult for her to open up. So she found a therapist that would have an email relationship with her and in that venue she was able to open up much more freely.

There‟s a big “dys-inhibiting” effect of online therapy, particularly if you don‟t have to look at someone face-to-face. This tradition actually may hail all the way back to psychoanalysis where the client is supposed to lie down with the therapist outside of their view so that they‟re not reading the facial expressions of the therapist, looking for cues. So in online therapy you get a very different kind of view of the patient. Now some would say that could be a very skewed view. Yes it could, if it‟s your only view of the client. It takes a little bit of getting used to particularly if it‟s only text.

ALEXANDER: Right, because you won‟t see any peculiarities of their appearance or idiosyncrasies of how they talk or look.

FREENY: Exactly, which is both a good thing and bad thing. The good thing is some therapists just have a wonderful knack of being able to read between the lines. In addition, there are little things called emoticons that you can add like a smiley face or a frowney face or something like that to convey some sort of emotion. But a lot of individuals find that this motive interaction has a richness all to itself, and sometimes they can see stuff in sentences that they may have missed if uttered in an office.

Now nobody thinks that this is going to replace traditional therapy, but clients are finding that this is very comfortable and it can be conducted at a variety of levels. For example, the therapist might be visible to the client but the client might not be visible to the therapist, at least for a while. A lot of people find that what they want to do is start off with some form of online therapy and then bring it into a regular face-to-face session.

ALEXANDER: One thing that strikes me about it is in the psychoanalytic sense, truly psychoanalytic. The therapist is truly a blank screen; the potential for projecting onto the therapist is just huge. Like listening to the radio or reading a novel, you have the picture in your head of the person. Of course, when you see the movie version of this novel and you‟re either disappointed or you‟re thrilled with the actor selected to play a certain character, but it seems like the therapist‟s anonymity would be a wonderfully rich resource.

FREENY: The Employee Assistance Programs (EAPs) have been doing therapy without facial cues for decades. EAP programs of the service companies often times will do the first level of intervention on the telephone. So they‟ll talk to the client, do an assessment, help them with their job stress and recommend some psycho-educational reading or something like that.

ALEXANDER: Like a typical intake interview that is over the phone, right?

FREENY: Yes, and as a matter of fact, for years the Samaritans in England have been doing both telephone and email suicide interventions with people they don‟t know, they‟re anonymous.

ALEXANDER: You‟re right. All the suicide hotlines are anonymous.

FREENY: Exactly, and yet they do good work. And the people who call may call specifically because of the anonymity.

This raises a really interesting issue because there are some regulatory changes that are coming that many of us believe are going to change the face of psychotherapy. The federal government has passed these new privacy regulations, and essentially the feds have granted themselves rights to medical notes, including psychotherapy notes. They have granted police officers the right to peruse medical records without the patient‟s knowledge, consent, or even court order, and marketers have access to some of this compiled medical data so that they can sell their products. Then there‟s of course the medical information bureau where if you file a claim, your medical information goes there, particularly for psychotherapy claims.

The population in general is coming to realize that the sanctity of closed door psychotherapy session has been violated and that the information is being transmitted all over the place into big databases. As this becomes more widely known, the question arises: Are clients going to trust us with their secrets if they know that we‟re required to transmit them to various and sundry places?

This raises another issue. If we are mandated to reveal our records and notes-- therapists are largely in the dark about how much of our client information is already transmitted; diagnosis and treatments, etc are widely available -- the question then becomes “Does patient privacy also include a right to patient anonymity?” If the only way to guarantee privacy is to pay cash under an alias, then clients might want to assert a right to be anonymous, with the therapist‟s full disclosure about the limitations of it. A lot of therapists might say, “Anonymous psychotherapy? That sounds crazy.” But again, we still have these strong traditions of help lines that have been doing it for years.

ALEXANDER: Well, isn‟t it possible for outside sources to tap into these chat rooms or into these online therapy sessions?

FREENY: It‟s possible. In fact email is notoriously leaky, depending on where it originates from and where it goes. It‟s usually not someone who‟s tapping into the direct connection like tapping into a phone line, but rather it‟s where the email goes and which server it goes through. But for every problem to this there are solutions. The two most common solutions for any kind of online work are to either: 1. make the material unreadable, which is called encryption; or 2. Make the material unidentifiable so you may know what somebody said, but you don‟t know who said it and you have no way of finding out who said it.

So if hackers get the personal secrets of BettyBoop269, and if they don‟t know who the secrets belong to, they can‟t do anything too harmful.

The first thing I do with my email clients are gage their technological sophistication. I explain that if we‟re going to have this exchange, let‟s open a free anonymous email account that will be

6 untraceable, and then if there is a compromise of material no one will know who it belongs to. So that‟s the easiest way.

Another way is called encryption, which is a little bit more technically demanding and requires special email software, which is freely available and most email software can do this. It creates a secure connection between email A and email B, or requires a password to “un-encrypt” the information. If someone gets the information, but they don‟t have the password, the information will do them no good and it will be very expensive to spend a lot of time trying to crack it. Hackers would much rather spend their time trying to hack into banks or something more profitable than someone‟s personal email. The other issue is that clients have to know has to do with whose computer they are using -- if they‟re communicating to you from their computer or somebody else‟s computer. If it‟s somebody else‟s computer, then you have to know where that email goes.

Now another method of communicating, the chats, can be very secure and there‟s millions of chats going on everyday. So if I‟m going to have a chat with a client, I will go to Yahoo, for example, and say I‟m going to create a chat. I will have to come up with a name for the chat, at which point I will have an option to say this chat will be private, that is, no one else can see it listed-- or public, that is that people can see it listed. So I can make it private and then I can also make it secure, meaning that no one can enter the chat room unless I admit them. If they “knock on the door,” I say whether they can enter or not. So it‟s private, secure and to the best of my knowledge virtually inviolate; there‟s no way to get there. Yes, there‟s information - digital information - corresponding between two computers, but the chats only going to last from a half hour to an hour, nobody knows it‟s there, nobody can get in, and then when we‟re done it completely evaporates.

ALEXANDER: Can you print it out?

FREENY: You can print it out and in the new regulations, depending on the nature of the relationship you have with the client and whether this is considered a medical record, this print out would become part of the patient‟s medical record.

ALEXANDER: You could de-identify the patient by…

FREENY: Correct, the patient would have to create an identity to come into the chat room, and you could just create one for them and say you‟re “Yankeedoodle,” so Yankeedoodle logs into the chat room and you have this interaction with him. If anybody gets the chat of Yankeedoodle, it‟s not going to do them any good.

ALEXANDER: How do you charge for this?

FREENY: Usually we charge by credit card. Some people who want to be completely anonymous will forward a money order and prepay for their sessions. Martha Ainsworth did that for a couple of years.

ALEXANDER: Would you pay by credit card like you would pay for anything else online?

FREENY: Yes. You could either give the therapist your credit card and the therapist could manually enter the information into a terminal at their office. Or, for example on my site, you should go to an e-commerce secure website and enter your credit card information there. Now lots of people are a little wary about entering credit card information on the internet but if you are at a secure site, which is easy to identify in your browser because of those little padlock icons, if you are there, there is no way anyone can invade that transaction. To date there is not one recorded incident of a secure interaction being violated. You hear that sometimes hackers break into a company and steal credit cards, but those credit cards are sitting on a database somewhere and it doesn‟t matter how they got there. If you paid for your dinner at a restaurant with a credit card, if they break into the restaurant‟s computers then they have your credit card number. So it‟s not the transaction that got invaded; it‟s whoever is keeping this on a database, so it‟s pretty darn secure -- probably more secure than handing it to a starving waiter because he can just make a copy of your credit card right there.

ALEXANDER: Well do you say it‟s a 45-minute session and so you charge X number of dollars?

FREENY: There‟s a variety of ways to charge and most people are starting to charge by the minute with sometimes fifteen minute minimums, and 30, 45, or 60 minutes. And that way there‟s a lot more flexibility in terms of the amount of time online. Clients like it because if you actually think about it, to physically leave your office or leave the house and get in the car and drive to see the therapist, that can take up to three hours out of your day for one session, whereas in computer time, kaboom you‟re there, and all that time is fully directed to the therapeutic process.

ALEXANDER: Well let‟s say that you‟re the therapist and you ask the client a question like, “When was your child toilet trained?” or something like that. Now there‟s going to be a period of time while that person is working out the answer. I mean maybe there‟s a day, and how does that get billed? I mean this is not consecutive minutes.

FREENY: It depends. If it‟s online synchronous, that is, it‟s a live interactive chat for example, or live face-to-face over the internet, then it‟s charged and timed just like a regular face to face session. What we recommend--if we‟re going to have an email exchange-- is that we‟ll email you the questionnaire of what we need to know, and then you can email that back, and then we bill for the time of review.

ALEXANDER: The question let‟s say, “Why do you feel that way?” -- that can take some time and the person is online. Is that charged for? Is thinking time charged for? Or let‟s say the person as I said comes back to you the next day with that answer?

FREENY: Well, we‟re kind of mixing up two different modalities. When you‟re in the therapeutic office traditionally and you say, “Why do you feel that way?” and they pause and think about it for a couple of minutes, you‟re billing for that time because you‟re sitting there in the therapeutic hour with them. In fact the delay in response to some extent conveys information to you just as it would in the chat.

One of the things you have to understand is that the faster the internet becomes the more immediate the interaction is. For example, I have a cable modem and if I see somebody with a cable modem, I can offer them options that really wouldn‟t be suitable for somebody that has a dial up modem because they would be fifty times slower than I am. So yes, there is a delay sometimes if you‟re chatting with someone who has a dial up modem, and you type an answer and it can be up to a minute or two before it appears. It can be a very slow process and what you have to do is sort of find the medium that‟s best for them.

Now most of the time I would prefer, after a few interactions in chat or email, that if they‟re out of my town, to have a telephone conversation with them. That‟s to me a superior medium, unless of course they have a camera and a high speed connection, because you get to see their face, you get to see the timing of things. I have a demonstration of that as well. It‟s basically doing T.V.-set therapy. Both of you are looking at each other, and you can see smiles and frowns and grimaces and body language, etc. So you have to gear the medium to the technology that‟s at both ends of the spectrum.

ALEXANDER: What theoretical framework is used most of the time?

FREENY: It varies as much as the therapists do. I know some that are very psychodynamic that use this, and for the points you made earlier, it veils the therapist‟s identity even more, which helps in projection and sometimes the transference issues. Others are much more cognitive/ behavioral or psycho-educational.

That‟s one of the interesting things about live internet interaction. Not only is it a transaction between you and the client, but you‟re both on the internet at the same time so you have all the internet resources that you could want. For example, if you think the client is depressed, you could direct the client to go to the National Institute of Health and take a little test on depression right then and there. Then instruct the client to email it to you (the therapist). The therapist could be there with the client and use the test questions as a springboard for conversation: Are you having difficulty concentrating, losing weight, etc. Then if the patient is depressed, you can refer them to books, psycho-educational materials, and even videos parked on the internet. So you and the client can be meandering all over cyber space picking up resources.

There are also hundreds of online help groups and support groups. There are groups for people that have common problems such as ADHD, or incest survivors, or alcoholics. Any disease or subject you can think of has online groups that have either regular meetings (that is at 3 o‟clock on Wednesday everybody logs on and they have a little chat), or they have what are called listservs or bulletin boards. This is where people have discussions about their concerns and

9 issues and post messages so that all the people in the group, which may be anywhere from five to 500 people, can share resources and information and empathy. The relationships that are formed by these people are very strong.

That‟s one of the things that has been such a surprise to all of us who have been using the internet. Most of us thought originally that it was going to be this teeny little supplemental thing to therapy. Maybe we‟d use email or something like that, but instead it has become this highly dynamic, highly interactive, and rich resource of all sorts of cool things that can be used to really benefit the client.

Now on the other hand, the “wild and wooly” Web is a little intimidating. There are some dangerous people out there, and we‟re dealing with vulnerable populations. One of the things that needs to be in the skill set of an online clinician is not only the therapeutic ability to interpret things and bring a professionalism to the interaction, but also enough technical knowledge that you can help the client protect themselves. Most therapists and I are pretty aggressive about that.

For example, in order to schedule a session with me, you have to read an entire section on privacy and confidentiality and what the risks are of each medium just to make sure that I can protect these clients as best as possible. There‟s a whole technological skill base that the therapist has to bring to this.

I had an interesting interaction where I had done one of my Yahoo “Love and Sex” chats and a gal queried me after the chat. Once in a while I‟ll answer a couple of stragglers. By way of explanation, in the chat there‟s thousands of people in there asking me about love and sex and I have a producer and screener and they pick out questions that I respond to. So as this chat closes, some people like to arrange for personal consultations.

So this one gal did and she was very suspicious that her husband was addicted to pornography on the internet, but she couldn‟t seem to catch him. She asked me what would I look for, and what were the signs and symptoms and stuff like that, so I referred her via the internet online in the middle of our chat to a couple of online resources that explain the signs and symptoms and what to look for. One of the things she discovered was how to check where the computer has been -- the history file of the web browser. So while we were chatting, she had another window open on her computer and she was now exploring her own computer and she ended up at a website which was a porno trading center. I had asked, as I routinely do, for her zip code in the event that I need to come up with resources for a person of a particular area. Routinely, it‟s one of the first things I ask for, just to know where they are in the country if I need to help them.

Well, she went to this porno trading site and not only was there lots of porno there, there were pictures of her there that apparently her husband had posted to share with his buddies, which immediately threw her into a very big crisis. And again this sort of speaks to how quickly things can develop. Fortunately I was able to call up resources in her area. I convinced her we should have a telephone conversation about this and she was able to follow through on that. But as you can see, it‟s a truly amazing medium that has both great advantages and great cautions as well.

I do a lot of work with ethics and I work very closely with my regulatory board and my professional associations. One of the things that I have done is really press the fact that we need standards. The rate at which mental health clinicians and mental health resources are popping up is staggering. If you go into a browser and just type online therapy, you‟ll get close to 10,000 hits now. It‟s so new we don‟t even have consistent name for it, so sometimes it‟s called e- therapy, or e-counseling, or cyber therapy, or online counseling. I mean we just don‟t have a standardized name for it. But again, lots of people are offering this.

It‟s interesting because clinicians who usually do this also usually have websites. On their websites they can have pictures of themselves, and their credentials, and links to this, that and the next thing, which is certainly what I have and just about every other clinician does as well. So it could be that the client knows a lot more about you than you would know about the client, and again this is very distressing to some people and they think, “Well how could you possibly do anonymous therapy if you don‟t really know who the person is?” And we counter that not only with examples from EAPs and suicide hotlines. Also, with clients who come in to a traditional face-to-face session and elect to pay cash, you never ask for a photo I.D., so they could basically tell you, and do, that they‟re anybody they want to be.

For example, airline pilots are terrified that if they seek therapy for depression and there‟s an official record linking their name to the word “depression,” that they could get their wings clipped by the FAA, so they often will come in and pay cash under an alias so they can‟t be traced. There have been cases where people come in and pay cash and start talking about stuff, and then reveal something that was reportable like in a child abuse evaluation, at which point the clinician told them he or she had to report this to the authorities. The person gets up and leaves the office, and the therapist tries to report it and it turns out this name and person don‟t exist. So there‟s an anonymity that occurs even in the office and we just don‟t know about it.

Anonymity is a very interesting thing. I have teens, and they are completely fluid with this and they‟re comfortable that they may not know very much about the person they‟re interacting with, but that doesn‟t seem to matter. They‟re interacting with an entity over the internet who‟s somewhere, and they can have a nice relationship, and they can have a friendship. My son plays games with people from Norway and Australia at the same time. They have regular contact and they chat in the little game chat rooms and do all that kind of stuff, and he really does feel that these are nice guys and they joke and laugh and do all that kind of stuff just as kids do on the phone all the time. So they have embraced this new media and they will be the clients of the future, of the near future actually. These future clients will fully expect the internet to be part of my communication with them, because it‟s part of my communication with everybody else in my life.

ALEXANDER: I bet it would be the treatment of choice for a lot of adolescents. They would prefer that to any kind of face-to-face.

FREENY: Absolutely, although there are issues of getting parental permission. That varies from state to state, and again, there isn‟t any consistency from one state to another about the legitimacy of online therapy. The state of California Psychology Board issued a proclamation that only psychologists licensed in California can provide internet counseling services to the residents of California. Do they have the power to do that? We have no idea because the licensure laws were developed long before there was online practice so we don‟t know that. Can they enforce it? Well to date there haven‟t been any law suits or malpractice suits about this. There probably eventually will, but to date no one has found one. We also know that in one study, 75 to 80 percent of clients were very satisfied with their internet counseling experience. So there‟s a high degree of satisfaction, probably as much as there is in face-to- face.

ALEXANDER: Who rates that, how is that done? Are there national studies?

FREENY: There are studies and surveys that are actually posted on the internet. Metanoia.org is a real good resource and clearinghouse for that, as is psychcentral.com; this is where all of us wacky therapists go to share stories, share experiences.

Back on the issue of licensure, so California has this regulation, how on earth are they going to enforce it? How are they going to enforce me in Florida when they have no jurisdiction in Florida? How are they going to enforce this against somebody in Great Britain who is seeing a California resident? They have no idea. I‟ve talked with the leaders of some of the professional boards and they‟re spinning around trying to figure out how on earth this is ever going to be regulated.

And again, with the issue of confidentiality, it may be that clients are going to assert that they have the right to anonymous treatment just as long as we tell them what the limitations of it are. For example, I have a clientele that‟s very established, very comfortable, very functional. I haven‟t had a crisis in a very long time and they have sufficient ego strength that I don‟t have to worry about them. For other people who see, for example, borderlines, this might be very inappropriate because the borderline would just find another avenue for more time and attention and just spam them with hundreds and hundreds of queries and desperate things and stuff like that. So we‟re just beginning to find out which cases or diagnoses, or personality types it works for and which it doesn‟t.

Now one of the things that comes to mind is that it wouldn‟t work very well for the chronic mentally ill. Well, that‟s not exactly true because Texas is in the forefront of doing telemedicine, which is basically what this all falls under: distance medicine by one means or another. From the cities, they are setting up telemedicine sites in rural areas and actually doing online counseling face-to-face with video and everything else in these difficult to reach places.

Additionally for people who are shut-ins, for example the elderly, it‟s a fabulous way to keep connected. In fact, one of the fastest growing things is jokingly called “the granny net,” because all these older people find out how cheap it is to communicate over the internet either with voice,

12 audio, or video etc. They can actually play board games and card games over the internet with their group of people. They bond and they form friendships. They also can check in on one another, so if Gertrude hasn‟t been heard from in a couple of days, they can contact her family or contact the local police and have them go by and check on her, including sending an EMT if somebody has a heart attack.

There is a connectedness and basically all the internet provides, when you get right down to it, is another way to communicate in a variety of different styles and fashions. Virtually everyone has heard about internet affairs going on, where people are meeting, chatting, and falling in love over the internet. People pooh-pooh that type of interaction, thinking how on earth could that happen. Well, it‟s very interesting because it happens kind of in reverse of traditional face-to-face settings. So if you meet someone in public face-to-face, you see instantly what they look like, and that may or may not be a deal breaker to further this conversation with this person. If on the other hand, you meet them in a chat room, then you will get to know their values, their humor, their wit, their intelligence, their sensitivities, the things they care about. You‟ll establish an intellectual, possibly an emotional relationship with this person before you actually see them and that could color your view of what this person looks like when you finally do see them.

Everybody has those stories of online affairs, and a lot of online affairs occur in innocuous shared interest rooms. So for example, if they‟re dealing with yorkies, they start talking about the joys of their yorkie, how smart their yorkie is blah blah blah blah blah. Then they‟ll instant message somebody in this room and say, “You sound interesting, do you have a picture of your yorkie?” And then they‟ll send one and they‟ll say, “That‟s interesting. Oh is that you in the background? You‟re a handsome chap.” And so now they‟re having a side conversation to the Yorkie club and they found out that they have a lot more in common and it drifts off the topic of Yorkies and they start talking about their lives. That‟s one of the ways that relationships happen on the internet with people, or even with therapists.

ALEXANDER: Malpractice insurance?

FREENY: I‟ve talked to the malpractice insurers and asked them this question directly. They said you are covered for online therapy as long as you don‟t break any laws… which is a heck of a disclaimer since nobody knows what parts of this are legal and what aren‟t. Also because most of the state laws-- the jurisdictions for malpractice are state-- we‟re not exactly sure who‟s going to sue whom or in which jurisdiction. Since this happened in cyber space, exactly where did the therapy occur?

For example, I had a client whom I hadn‟t seen for five or six years, and she had a big medical crisis and it threw her into a relapse of alcohol about a week before I was scheduled to be in London, England. So I said I‟m going to have to get someone to cover for me while you‟re going, and she said, “Well, I want to continue talking to you,” and she suggested via email. So we created a bogus email identity for her and I went to cyber pubs over there and had a couple exchanges with her across the Atlantic. Well, where was I actually practicing? She was in

Florida; I was in London, so where was the practice occurring? These are questions that are going to be hammered out in the next 10-15 years about what it is and where it is.

ALEXANDER: Well, aren‟t you as the therapist a little vulnerable, because let‟s say you‟re doing online therapy with somebody and all you know is her name is Pocahontas. Then let‟s say Pocahontas wants to sue you later on. Then what? I mean they could sue you, they know who you are…

FREENY: They know who I am, and that‟s one of the unnerving things about online therapy. A lot of online therapists comment on the fact that their credentials are usually posted on the website or on some of the bigger online clinics such as heretolisten.com or helphorizons.com. It‟s disquieting that an online therapist knows only what the client wants them to know, and the client can know a great deal about them, and yes someone can sue you for any sort of things. I‟m sure that will come up but so far it hasn‟t.

A lot of lawyers are of the opinion that it would be very difficult to sue a therapist across state lines for some legal rationale that escapes me, but that was a set of opinions. Again we don‟t know. Also some of us are taking the cautionary note and saying that what we‟re doing is “consulting and coaching.” I‟m not calling it psychotherapy and I have a description on my site that distinguishes between what psychotherapy and counseling is, and what consulting and coaching is. I don‟t offer them a diagnosis and I won‟t bill their insurance and all that kind of stuff. Other people are doing formal diagnosing and we largely do not know. This is a very grey area and many of us are really trying to get the boards, the powers that be and the courts to speak to this issue and look for any kind of precedent, but there are hardly any precedents.

ALEXANDER: It‟s so new.

FREENY: It‟s kind of a brave new world, and it‟s growing by leaps and bounds. I think when I did a search for online therapy about a year ago, I got probably about 600 hits. Then I did one three months ago and it was up to 8,100 hits. If you do one today I‟m sure it would be 10,000 hits, particularly if you used a really good search engine like google.com.

ALEXANDER: How many online sessions would you say there were last year?

FREENY: It‟s really hard to say. We know that there were 60,000, I believe, in the known formal programs, like the telemedicine projects in Texas and a couple of other states. I‟m blanking on them now…the ones that are promoting this. And then there‟s the big clinics and then you have to decide what exactly is online therapy and when do you know you‟re having therapy. What is the nature of the interaction that must occur for this to be called “therapy?” So there are sites that do more psycho-educational stuff--you can do a little online assessment, you can read up on diseases and you can try some simple interventions. Is that part of psychotherapy?

Then there‟s the full blown interactive nature. So number one, it‟s sort of ill defined what exactly it is, but there are at least hundreds of thousands of sessions a year and most likely it‟s going to be millions of sessions in a year. The sessions among the seasoned clinicians that I‟ve spoken with tend to be of shorter duration, both of the time allotted and in the number of sessions, anywhere from ten to twelve. Although Martha Ainsworth had two years of weekly email therapy with multiple emails in the course of a week, she just paid a flat rate to her therapist and they got comfortable with the pacing of the interaction and all that kind of stuff.

So it‟s going to be a very difficult time tracking down how many sessions occur largely because they‟re not being billed; insurance won‟t pay for them as yet, although Medicare has authorized some telemedicine services. Psychotherapy is one of them but that very well could change anytime. So in answer to your question, there‟s probably gazillions of sessions that are going online but it‟s real hard to count them because therapists are not promoting it too widely because there‟s all this legal mumbo jumbo and no one wants to serve their head up on a block and become a test case.

ALEXANDER: If you had one piece of advice for a therapist interested in getting started doing this what would you tell them?

FREENY: I would say scour the net for all of the mental health resources that are already there. Go to a couple of mental health and counseling sites and see what their disclaimers are. See how they discuss the issue. It‟s very important to educate the client about the good, the bad, and the unknown of this new medium.

Now there‟s another problem with vulnerable populations looking for advice, because there‟s a number of sites that consider themselves “advice central.” Go to a place called keen.com and you can get advice for computer stuff, automotive stuff and personal advisors. Mixed in with personal advisors are psychotherapists, psychics, clairvoyants, and people who have no credentials. There‟s even an “Auntie Maime,” who always seems to have great advice. There‟s very little way for the public or the consumers to distinguish one from the other, who‟s credentialed, where is the accountability. It‟s difficult finding legitimate “portals” of online counseling. Many places are trying to find these sources. Web MD is trying to become a big central portal of legitimate healthcare. Legitimacy is an interesting question, as clients demand this. This is being driven by clients; it‟s not being driven by clinicians. If clients want mental health services in these new ways, they‟re going to get them from somewhere. We have a new task ahead of us.

ALEXANDER: Mr. Freeny, thank you very much for not just an eye opening, but an eye popping interview.

FREENY: (Laughter.) Get comfortable with the internet, because it‟s not going away anytime soon.

This concludes On Good Authority‟s interview with Michael Freeny. We hope you learned from it and that you enjoyed it. You may contact Michael Freeny at [email protected].

I need to say here that the views of our speakers are theirs alone and do not necessarily reflect the views of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.

ONLINE THERAPY: CLINICAL and ETHICAL ISSUES

Interview #2: “Clinical Theories and Skills”

SUSAN MANKITA, LCSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Susan Mankita, LCSW 14120 S.W. 72nd Avenue Miami, FL 33158 305-773-1496 E-mail: [email protected]

Welcome to On Good Authority. I‟m Barbara Alexander. You are listening to or reading Interview #2 from our program on the clinical and ethical issues involved in Online Therapy.

Is Online Therapy, in its own right, a form of therapy? Originally it started out as a method of delivery of therapy – a means of communicating between two or more persons usually separated by large distances. Over and over, we are warned that we should not think of online therapy as a replacement for traditional face to face psychotherapy–that it is for use in certain situations only, if that.

The irony about the burgeoning of Online Therapy, which is, of course, verbal only, is that traditional psychotherapy has become, in recent years, much, much more aware of the significance of non-verbal communication! The physical boundary of the therapy office has become a metaphor for physical holding–the holding environment. But Online Therapy (OLT), without this shared physical space, eliminates the ability of the therapist to attune with the patient or client through facial expression, eye contact, gesture, and movement. It is too easy to hide for persons whose issues concern the distance they maintain between themselves and others.

But in this past decade, OLT has become, for many, the treatment of choice. As time goes on, new theory about it develops. The Internet can change the ways we connect with our clients and expand what we have to offer. Now, as therapists learn more and more about what works and what doesn‟t, totally new skills and methods are emerging that are making for a quite new kind of interaction between client and therapist. Perhaps with its intrinsic separation, online therapy can create a unique environment in which meaning can be found, and people who would never 17 have sought help due to fears of intimacy, fears of dependency and engulfment, can begin to approach the therapeutic experience.

Our speaker in this interview presents both some of the emerging theory underpinning online therapy and clinical skills necessary to do it.

Susan Mankita, known online as SusanLCSW, a.k.a. HOST WPLC SocWk, is a licensed clinical social worker, practicing in Miami, Florida. She is a Ph.D. candidate studying social workers on the Internet.

Since 1995, Susan has worked to mobilize a community of social work professionals, through the empowering collegial networks available via the Internet. Susan developed and leads the Social Work Forum in America Online. Under her leadership, the Forum has grown from a small set of bulletin boards to a full and rich community of social workers, including a 2400+ person mailing list, multiple weekly chats and a staff of community leaders committed to enhancing the Internet experience for social workers.

She is currently a consultant with All Care, Inc. and eTherapy.com for whom she has developed a professional training guidebook for eTherapists. Susan enjoys nothing more than to present professionally and has done so all over the US, on topics including: “Professional Empowerment”; “Powerful Communication Skills”; “Developing Professional Identity” and “CyberOpportunities”, Internet workshops. Susan wrote, directed and co-edited a video, called, Social Worker’s Health Care’s Hidden Heroes. An adjunct faculty member for Barry University School of Social Work, her articles have appeared in multiple local, state and National publications. Interviews with Susan appear in two books about the Internet and human services.

ALEXANDER: Ms. Mankita, we are here to talk about the specific skills needed for doing online therapy. I understand that you have done many seminars with great success and enthusiasm on online therapy--its use in chat rooms and other online groups. Where do you usually begin in your presentation?

MANKITA: I talk a lot about the skills that clinicians should have if they decide they want to practice in this way. I think a lot of people who are now really excited by this prospect are ready to jump in. I usually advise against that because there are skills that they may not necessarily have. Being a wonderful face-to-face therapist doesn‟t necessarily translate into being a wonderful therapist on the Internet. There are different theories that inform online practice, and you should be aware of them. These new aspects of a therapy session greatly impact the relationship and are really important to the therapist. They include:

dis-inhibition and how you will not being able to see to whom you‟re talking; not having patients see you; and the fact that you don‟t have any social cues to know about the client. You want to know

how the client perceives you. You won‟t know what your biases are going to be when you can‟t see a client, and of course we‟re talking about chat here.

There are other mediums, but for the most part, right now at least, most of the communication is taking place in a textual way with written words. First there is communicating by email that is more like a telephone answering machine where you type something to the client, he or she gets it and keeps it to think about responding, and vice versa. This is Asynchronous. Second is chat (texting, instant messaging), which happens in real time and you have to be able to think quick on your feet, and certainly therapists need a lot of skill if they‟re going to try to do that Synchronous medium.

ALEXANDER: Tell us about “disinhibition.” What do you mean by that?

MANKITA: There‟s a ton of theory about disinhibition. Essentially what it means is that people who are interacting online and can‟t be seen tend to feel less afraid of revealing things that they might ordinarily keep to themselves. We have inhibitions because we live in real communities where certain things are just not socially acceptable. When you‟re on a computer and using given current technology, most people don‟t know who you are because they can‟t see you. If you‟re unhappy about what people think about you on the internet, currently, you can change screen names and become somebody else. Because of that, people tend to reveal more than they might if they were looking you in the eye. People who want to do this often come because of privacy issues and shame-based issues. For example, a person might have something going on in his life that‟s extremely private and personal, or he might be a well-known community person or an actor or a politician.

For notable people and/or for many people who may have stigmatized issues that they don‟t want to share, the internet allows them to share more freely. The Internet provides the opportunity to be less known when they want to reveal things that are quite personal, and things with which they‟re uncomfortable. An example that I use is to ask whether you have ever had a difficult conversation in a car. Sometimes the conversation proceeds more easily because you‟re not looking into the face of the person with whom you‟re sharing the difficult information. So in my family, when we had hard things to talk about, we did sometimes start them up in the car where we weren‟t looking at each other.

Then there is de-individuation. De-individuation theory is used to describe what happened in Hitler‟s Germany, with the Nazis actually. It‟s what happens when people become part of a larger group and they don‟t know a whole lot about each other. The result is that the group norm becomes primary. On the internet what happens is that group norms start developing and people start adapting the value system of the people that they‟re part of on the internet. For example, in the social work forum that I run, we‟ve developed a set of values that people to begin to ascribe to in hardly any time. People want to be members of this desirable group and I think probably other things are operating too.

People “project” onto others that which they believe about themselves is good. So for example, there‟s this theory that builds onto the de-individuation that is called a social-individuation and de-individuation theory. When you meet somebody and want to know more about them but don‟t have the cues that you need, you construct favorable impressions. People make up these favorable impressions so that they think they like these new others and that the people whom they are learning to like through the internet are a lot like them.

Part of that explains why people fall in love on the internet. It‟s sort of a constructivist view. It says that we create our own reality and we make people a lot like us because we don‟t have the cues to tell us otherwise. Even when we do that in a face-to-face meeting, we get to know people by projecting our wishes upon them.

Here‟s another one. Joe Walther did the Hyper-Personal Relationship theory and he speculated that when people meet on the internet, they already have something in common, and then when they try to get to know each other further, they‟re able to present themselves in a more selective way. When they meet and find a common bond, people choose not to share further right away anything potentially perceived as different or getting in the way of a romantic relationship.

For example, if there‟s something about me that I believe gets in the way of my getting close to people--whether it‟s the color of my skin, or a physical difference--then I don‟t tell people that. For instance, I‟m very short, but I don‟t tell that to people first. People who meet me face-to- face, however, know that. So in other words, people present themselves more selectively and what happens is when they‟re part of a group or part of a relationship on the internet, they can control impressions. Remember, a lot of this is text-based so people can consider what‟s being said to them, and then they don‟t need to fully respond. They can respond partially, they can be selective, and so people are presenting themselves in this heightened way, and the people that are reciprocating are also presenting themselves in a heightened way. So between idealizing the other because of how we construct views, and our own impressions that we put out there, there‟s this cycle, this loop that‟s created that really contributes to intense physical relationship. A therapist needs to know this stuff because otherwise when a client discloses in a way that seems rapid, it can be confusing. There are so many things that a therapist needs to know.

ALEXANDER: Any other theoretical observations that people have learned from the internet from studying internet?

MANKITA: There‟s Tele-presence, the Social Presence theory which is Williams and Christie, from 1976. They speculated that increased social cues lead to an increased sense of presence.

ALEXANDER: So what does that mean in terms of…?

MANKITA: Well remember, on the net we‟re not yet using much video or voice, and when we‟re talking about text-based chat, there aren‟t too many cues. So according to their theory, people are going to not feel like they‟re part of something. However, what they say is that the

20 more cues you can add, the more you feel that you are not alone. This is called social-presence-- or tele-presence. In other, the higher bandwidth there is on the computer, the more that‟s available on the internet through the medium, and the more you‟re going to be able to connect and build a relationship with somebody.

ALEXANDER: What does bandwidth have to do with it?

MANKITA: The widest bandwidth would be face-to-face and the most minimal bandwidth would be something like email, where there really isn‟t a large connection. Video would involve significantly more bandwidth than chat takes up and so on.

As a therapist you need to know that the choice of medium is going to impact how people perceive you. The more cues they have, the more chances of a sense of warmth and friendliness coming through. And of course we know that the more warmth people feel, the more satisfied they are with their interactions. As therapists, we want our clients to perceive therapy as helpful and satisfactory.

So there are things that you can do to increase that sense of social presence for your clients on the internet. The more interactive you can be, the more cues you can provide, the better. Even if you can‟t see people, you can provide cues to them. You can describe yourself during your sessions in typing such as: “If you could see me now you‟d see that I‟m smiling,” or “If I were there I might want to hug you right now” (depending upon what therapeutic model you use). By doing that, you‟re modeling to your clients that you want them to talk about and think about their feelings. Certainly when you do things that way, you really do give the clients pause to look at their own physical appearance and tell you what it is. I might ask a client on the internet that because I can‟t see him or her: “I‟m interested in whether you‟re smiling when you say this,” or “What is your body is doing? Are you twitching, are you sitting calmly, do you feel any tension in any way?”

There‟s a whole body of theory from linguistics that I think practitioners need to know if they‟re going to work in text. Some are theories about coherence. What we learned about linguistics and language basically were the skills that are required in face-to-face relationships. Some of this I think we just learned growing up in communicating. For example, there are rules to speaking with somebody--we speak in order--you speak, I speak, you respond, I think about it for a second, then respond. I think these are theories of “interactional coherence,” in linguistic theory.

Other rules of communicating face-to-face are that there should be no gap and no overlap. “No gap/no overlap” is the rule. This means that when we speak face to face we don‟t talk on top of each other, and we don‟t wait too long. In therapy there‟s this silence thing, but that‟s a notable exception to the face-to-face rule.

On the internet when therapists use synchronous communication such as chat, there‟s this lack of coherence in communication that really requires some basic skill building. When you first start

21 doing treatment with a client, it feels awkward, and unless you and your client are really skilled at getting beyond the typical kind of face-to-face protocol, you‟re in trouble. Clients start feeling awkward and a therapist starts feeling like the clients are not listening, or fearful that the clients think that the therapist is not listening. I think it basically understands that new protocol emerges when you‟re communicating that way. You have to practice overcoming these challenges to effective communication on the net because what we understand about face-to-face linguistics is not there, but all the restrictions that we have face-to-face are minimized on the internet.

As a result of that, both the client and the therapist need to develop a filtering system so that when things don‟t go the way that we expect them to go in face-to-face environments, we have a sense of humor about it. Rather than having it feel as chaotic as it does when you first start doing this kind of stuff, it can almost become humorous and playful. While I‟m not suggesting that therapy need be humorous and playful all the time - the skills that you develop doing this over time really can help you build a relationship, build a therapeutic bond with your clients and move ahead.

The good news is that studies have shown that the more you do a certain kind of thing, the better you get at it. Even studies of certain psychotherapeutic treatments say that different mediums become more effective over time, because the users learn how to do them.

This brings me to something really important because I just came back from speaking to the Association of Social Work Board where we got into lots of talks about what competencies were required for the therapist. We also discussed whether we should regulate the skills that a therapist should have to do this sort of thing, and what are the minimum competencies associated with really effective online treatment. So even though we know that people get better after doing this over time, we have to be better before we start because it‟s in most of our professional codes of ethics. It‟s clear that we need to be qualified to provide the skills and services that we‟re going to provide.

A therapist should be practiced in the medium--whether that‟s email, chat, voice, or video. At the conference I demonstrated that even though we‟re fantasizing about how wonderful video will be, there‟s a lot to know. It‟s really hard to get the thing set up, and if it‟s hard for you, and if it‟s easy to get bumped out, then think about all the housekeeping items you‟re going to have to do to get your client to the place where you are.

Normally we have to be where our clients are but on the internet, it becomes more of a mutual process, because if you‟re communicating with her and you get bumped, or your technology fails, or her technology fails, what kind of back-up plans are you going to make? How are you going to be sure that you‟re not cutting things out right in the middle? You know, we have this whole professional thing about not abandoning our clients, well there‟s now an immediated environment, where we have to really be sure to not abandon them. Could you imagine that? Can you imagine a therapist working with a client who reveals something so sensitive and then having your technology go down? And if a therapist is going through one of those companies, one of those big mega companies that‟s advertising now and trying to get therapists online to do

22 practice, they may not have as much power to get back to their clients as need be. So another thing therapists need to know is when they choose to affiliate with one of the big online practices, they must understand what their rules are, and how available client information is to them.

Therapists need to know what to do in the case of an emergency, not just a technical emergency, but also what if the client is in crisis? What if, despite many therapists‟ best efforts to use disclaimers about people who are suicidal and encourage them to call 911 and the police, we know that suicidal people don‟t necessarily do that and we may wind up with a suicidal client on the other end of our computer communication. What do we do? So therapists need to learn how to do crisis intervention on the internet.

Therapists need to be prepared, and they need to learn how to start out their online relationships in such a way that the clients know certain rules. Consumer awareness for our clients is critical to our value system and our ethical codes. We have to have informed consent, and informed consents means our clients need to know: a) That this isn‟t proven yet, although anecdotally some preliminary studies show that this can be really effective, but the clients need to know that this is not face-to-face stuff. b) We need to inform clients about what to do in an emergency. c) We need to teach them how to communicate, d) We need to model good text-based communication if we‟re using text-based environments.

So there‟s a ton of things that a therapist needs to be prepared to do, and I encourage them to take all the time needed (days, weeks) to get comfortable in an online environment.

If you‟re going to do email, there are things that you really need to know. Here‟s a good example: if your client and you agree that you want to do email communications, how do you know that the private content you send to your client is going to be read only by your client? Many families have shared email addresses. You need to discuss this with your client, don‟t you? You need to make sure that if you put in the subject line, “In response to your thoughts,” or “From your therapist,” how do we know that your client‟s 14-year old kid isn‟t going to find that really interesting?

And speaking of fourteen year old kids and hackers, how do therapists protect the highly confidential and privileged information that they are going to be getting? There will be email going from your client‟s email box to a server and then into your email box, and living on the hard drive of your computer. How are you going to protect that information? Remember that when we‟re doing things in text, it can be saved, manipulated, it can be switched around, it can be used against you in the court of law. How are you going to protect your end of the confidential communication?

ALEXANDER: How?

MANKITA: Aha! I talk about that for a whole day when I train therapists. It all comes down 23 to the fact that you have to protect your stuff in the same way that we put our written notes under lock and key. Liability for the therapist is another gigantic area, and of course when I talk to therapists, they are very fearful. They want to know whether their license will be at risk. At least in the world of social work, the jury is still out on that because regulators are just talking about whether they want to regulate, whether they want to see if they get complaints and handle each complaint at the time.

On the internet you can see a client in Kalamazoo if you live in Miami, so who‟s going to have authority for that? So there are a whole lot of questions that are unanswered. Will my liability insurance cover that? At the moment the answer is yes, although I suspect that therapists are going to need to stay on top of their liability insurance companies because the minute there are lawsuits, that could change or it could change to maybe a rider. You know, when we speculate about what‟s going to happen in the future, we know that anybody who‟s going to do this work is going to learn what questions to ask. And they‟re not going to ask those questions once, because everything‟s changing so quickly.

ALEXANDER: What about specific clinical skills?

MANKITA: There are a lot of them, the jury is really still out on which therapeutic styles are going to work best in which medium. Let‟s start with assessment, because when you assess a client you want to know: is this type of treatment the best possible way to meet the client‟s needs? One way of doing that is looking at level of care. My good friend and colleague, Gary Stofle, wrote a book for consumers on how to choose an online therapist. In it he has a little piece called, “levels of care,” where he tells consumers about different kinds of psychological or mental health treatments and what types of therapy would be appropriate. He wrote that if you‟re experiencing different kind of things, your needs might best be met in a face-to-face environment, or in a hospital, or in a more intense environment, or less intense.

I think we need to do more kinds of work like that, because I don‟t think therapists know yet who is going to be best for this medium. Those who may be best are certainly people who have lives already on the internet, people who are part of online communities, and those who spend a lot of time on the internet, and who understand that communication protocols.

Another category would be people who are good writers. When we think about assessing people for therapy and when we‟re trying to figure out what their needs are, one of the things we need to make sure of is that people know how to write on the net, that they express their thoughts well in writing. So part of the early part of treatment really needs to be talking to them about what best will serve them.

ALEXANDER: That puts a lot of the responsibility then on the client.

MANKITA: On both, because clients don‟t always know what the best way to communicate is. If clients always knew that therapy would help them, we certainly would have a lot more people in therapy.

I think that what happens though is people are now more willing to take risks because it seems like there‟s less danger. There‟s sort of an easy out: if you try internet counseling and you‟re not happy with the way it works, you can sort of disappear and I think clients like that. So I think we need to be able to assess whether they‟re going to benefit from this, and we need to be able to counsel them towards face-to-face therapy if we believe, as therapists, that the scope of our practice on the internet is not going to be adequate.

ALEXANDER: The thing that keeps occurring to me is how, when managed care came in, therapists who were very psychodynamically oriented had to learn how to write in behavioral terms. They might work in psychodynamic terms, but they had to write in behavioral terms, and I guess I‟m wondering if that‟s the same thing here, if there are similar processes that we have to relearn here…

MANKITA: Yes. Do we know what all of them are going to be? No, I don‟t think that we have enough outcome research at this point to really know which therapists‟ skills are going to be the premium. But if I could summarize the clinical skills, I think that a therapist needs to be aware of the treatment models that so far are proving effective. Although as I have said, there are no really good outcome studies yet to prove this but at least anecdotally, and based on what clients and therapists think are working, the narrative approach …

ALEXANDER: Does that appear to be working, or does that appear to be a very useful approach?

MANKITA: Well sure, because people get to tell their stories and it‟s in writing. You could almost think of the written language as journaling, or co-creating the story of your life, and rewriting the story of your life. Certainly on the internet, the understanding of identity is altered. People can experiment with alternate identities and so in some ways, they can even be guided by the therapist to reinvent things about their own personalities that aren‟t working in their lives. The possibilities are tremendous.

I think people try to compare online therapy to face-to-face so much, but it‟s not always the correct question. Are online therapy and face-to-face therapy the same? No. Are there certain things that we can take from the world of face-to-face treatment and apply to the internet? I think so, but we‟re at such a new stage right now. I think that any clinician who wants to do this needs to be prepared to study the outcome of the work they do--whether that‟s single case design, or by putting some together, or by joining a group like the International Society for Mental Health Online and participating in its work. I think that we need to be sure that we‟re responsible when we‟re doing this kind of practice.

ALEXANDER: It sounds like there is no answer yet.

MANKITA: There are so many things that I learned as a social worker, and during my supervision, and of course my ongoing work and thoughts about relationship and mental health practice, that I apply to my relationships on the internet. I do run groups of therapists on the

25 internet, but the groups are for the social workers and function as support groups and case consultation groups and educational groups. So I do understand that there is almost a cognitive perceptual skill that one develops that includes filtering, so that we can interpret the kind of things that are going on in text-based real time communication.

One skill is the therapist‟s own cognitive perceptual abilities to work in this environment. Another really good one is how therapists can dissociate in the same way that their clients do. We separate our mind‟s components into more than one direction at one time, particularly when you‟re running a group on the net because it‟s almost impossible to keep the group so focused that there‟s only one thread of conversation going on at one time. You have to put your attention to more than one thing and allow your brain to pull out what‟s most important. I would hate to be running an online group where one of the members drops a bomb and says something that‟s so revealing, and puts himself out there so far, and then have it get lost in the chaos, in the noise of the chat room.

If you‟re going to run these groups online there‟s a whole other set of skills that you need to have, and you asked me about clinical skills, so let‟s talk about the clinical skills of a group leader on the internet. There is some group work going on in the online therapy domain already. Some of it is done via bulletin board, some of it is done on mailing lists, and some of it is done in real time chat. I don‟t know of any programs in which you can do video groups, but I suspect that that‟s not too far down the pike. If you are going to run a group on the internet, you need to be able to moderate it in a way that really protects the group members and keeps things in a certain order that minimizes the chaos for people, and there are ways to do that. There are ways of focusing the conversation, keeping people on topics, reminding them that there are human beings on the other end of the type written words so that they don‟t attack each other.

There are tools that you can use if you run a group online, if you choose to, that are really helpful. You can use instant messaging while you have everybody in a chat room to get a quiet member of a group to speak up or check on them and make sure they‟re ok. Because remember, when you‟re running a group on the internet you can‟t see the other participants of the group, but then you have to ask yourself questions such as, “How do you want to build group coherence? Do you want to have a highly structured group in a chat room where people can‟t become friends, or do you want to encourage them to talk to each other outside the group? Do you want an open-ended group or a close-ended group? A lot of the work in groups on the internet centers around getting people connected to each other, and so you have to be able to use your text-based skills to do that in the same way that you would face-to-face.

I run groups of therapists face-to-face, that‟s what I do for a living now, and I do supervision groups, and I do individual supervision too, and some of the stuff that I used to do face-to-face, I find myself doing on the internet all the time. To quote Yalom, I go horizontally instead of vertically, so when I‟m running a group on the internet, things may not get real deep but the discussion goes around process. “What is it like to communicate to your colleagues in this environment?” In the same way that a face-to-face therapist would say to group members, “What does this feel like to you to say what you think in front of your colleagues?” And then on

26 the internet the question is, “What does it feel like to say what you think in front of your colleagues in this environment where you can‟t see them, where you‟re typing at each other, where things seem a little chaotic?” So the process is discussed at great length.

I think that people who are used to doing groups face-to-face are surprised by how much housekeeping is required in a text based environment. So if you‟re a therapist and want to do this you need to decide how you want to do it, you need group rules, and you may want to post them on your site, or you may want to interview people for your group on the telephone ahead of time. A lot of decisions need to be made; this is not something you can just jump into.

ALEXANDER: Where can we learn more? Would the best thing to do to come to one of your chat rooms, come to one of your groups? Obviously to go to seminars, but you can‟t be every place at once.

MANKITA: I actually think that the best way to learn how to do this is through a combination of seeing people who do this face-to-face, and watching them do it. Not just on the net, but face-to-face, with sort of a mixed modality approach. I also think the way to do that is in chat, by practicing chatting, by practicing instant messaging, by sharing emails, and there are places that can be done. I know of people--and I am one of them--who are developing therapist training programs in order to give people what they really need to know so that they can safely serve clients on the internet. . . at least safely based on our current level of knowledge.

ALEXANDER: Is there anything that you‟d like to add?

MANKITA: I‟d like to talk a little bit about the equality on the internet and how that might affect a client and the therapist. Remember that when you see a client on the internet you see them in your virtual office, rather than your actual office which is filled with your stuff; your diplomas, your chairs, your books. It really changes the client therapist relationship and puts you together on a different and more equal level. Remember that what becomes most important is the communication, not the social status, not the appearance, not the age, the gender, not race -- those aren‟t as important as what‟s being said.

By the same token, given that model, there‟s a blurring of boundaries, and therapists need to be acutely aware of boundary issues. I‟m not exactly sure how that‟s going to play out. What are different boundaries going to do to the therapeutic relationship? But these are the questions, these and hundreds of others that therapists need to start asking if they want to provide this kind of service on the internet.

So in conclusion what I would say is, I‟m really glad that therapists are thinking out of the box, and want to meet clients where they‟re at, which is on the internet. But by the same token, we have a professional obligation to practice responsibly. I would encourage anybody that wants to do this work to fully learn what they need to do to run a good practice, to protect consumers, and to add to the knowledge base so that we can do efficacious work. That‟s it.

ALEXANDER: Ms. Mankita, thank you so very much for this highly informative interview.

MANKITA: Oh, Barbara, you‟re so welcome.

This concludes On Good Authority‟s interview with Susan Mankita. We hope you learned from it and that you enjoyed it. Listeners interested in contacting Susan Mankita may do so at [email protected].

I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.

ONLINE THERAPY: CLINICAL and ETHICAL ISSUES

Interview #3: “Psychoanalytic Psychotherapy Online”

KERRY SULKOWICZ, MD

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Kerry J. Sulkowicz, M.D. The Boswell Group, LLC 151 East 80th Street, Suite 1B New York, NY 10021 212-737-1542 E-mail: [email protected] Website: www.boswellgroup.com

Welcome to On Good Authority. You are listening to or reading Interview #3 from Online Therapy.

We turn now to the subject of psychodynamic psychotherapy online. Most writers have taken the position that such work –such long term, relationship based work--is not possible online and, moreover, should not be done online because it allows the patient or client to avoid the very issues and areas that are at the heart of his or her problem – struggles with intimacy. The thought here is that the composed textual nature of email makes it an easy place to hide from sharing emotions–all you have to do is not write about them. The clues that a therapist might use to decide that information is being withheld won‟t be there without the body language of face to face communication.

But, since necessity is the mother of invention, isn‟t it possible that new theory and new developments will occur to make psychodynamic psychotherapy online feasible? Obviously the jury is still out on this–we are just beginning our voyage to where none have gone before!

Here to share his thoughts is Kerry Sulkowicz, MD. Dr. Sulkowicz has been a practicing psychoanalyst and psychiatrist in New York City since 1989. He began consulting to businesses and organizations in 1997 as a natural outgrowth of his interest and experience in understanding human motivation and behavior, and his extensive experience treating executives and 29 entrepreneurs. One of the founding members of the American Psychoanalytic Association's Ad Hoc Committee on Corporate and Organizational Consulting, he has consulted to Internet startups, entrepreneurial companies, family-run businesses, a buyout firm, and a traditional management consulting firm.

In addition to his consulting work, Dr. Sulkowicz maintains a private practice of psychiatry and psychoanalysis. He is currently Clinical Associate Professor of Psychiatry at the New York University School of Medicine, where he received the Distinguished Teacher Award in 1996. He is also a faculty member of the NYU Psychoanalytic Institute, where he completed his psychoanalytic training.

ALEXANDER: Dr. Sulkowicz, I‟m going to refer very often in this interview to the paper that you wrote and presented at the American Psychoanalytic Association meetings on the impact of the internet and telemedicine on psychoanalysis. Now this is going to sound like a joke, sort of a slapstick joke, but here‟s my first question: How is the internet like psychoanalysis?

SULKOWICZ: I don‟t think it‟s like a slapstick joke at all. I think there are some striking similarities and some similarities that are a little less obvious. When I‟m talk about the internet, I‟m really talking primarily about communicating via the internet, especially through email. One of the immediate parallels between the internet and psychoanalysis is the lack of direct face to face contact between analyst and patient in analysis, because the analyst generally sits out of direct view of the patient, behind the couch. This is a similar arrangement to the use of email in the sense that the two people corresponding are not looking at each other. That‟s one similarity.

What I think is also a similarity, but perhaps a bit less obvious until you get to think about it further, is the observation that a number of us have made, and that is that when people are talking in analysis, there is an intentional desire for the patient to speak in as uninhibited way as possible. The analyst, through various aspects of his or her technique, tries to encourage people to say whatever comes to mind and not pay attention to the usual kinds of social conventions that inhibit speaking in an ordinary conversation. Similarly, it‟s not exactly the same, but in the use of email, I think a lot of people find when they correspond using that medium that they write things that they wouldn‟t ordinarily say in a face-to-face conversation. So there‟s this relative lack of inhibition in an email.

ALEXANDER: Let‟s not forget the delete key, as you said in your paper, which enables you to take your words back in an email which you can‟t do in a conversation.

SULKOWICZ: Right, well that‟s an interesting thing too. That‟s absolutely true, you do have that option and people of course use it and it lets people be quite a bit freer. If you have a second thought about something, it‟s quite easy to delete it, whereas in the conversation of course that‟s impossible. Another interesting thing that contradicts what we‟ve just been talking about is that despite the presence of the delete key, a lot of people don‟t use it very much. A lot of people type what they‟re thinking and then almost impulsively they press the send key instead of hitting the delete key. So there‟s a capacity for deletion and editing, but there‟s also the possibility of

30 very spontaneous if not impulsive conversation as well.

ALEXANDER: It has made for more angry relationships I think, hasn‟t it? In other words you can send an angry message and it can be easily misinterpreted or interpreted correctly?

SULKOWICZ: Right, I was going to say it‟s not necessarily misinterpretation. I think that what one thing that‟s related to what you‟re talking about in terms of angry messages is that it‟s well known that if you‟re angry at somebody in conversation, a commonly observed phenomenon is that you break eye contact--unless you‟re really quite comfortable with expressing those kinds of intense affects like anger. It‟s a lot easier to confront somebody if you‟re not looking at them. So similarly with email, you‟re not looking at them so you can write using quite angry language. I think also this inhibition probably allows people to get much more deeply into their feelings about something in an email exchange. So while the ordinary conventions of conversation might inhibit that or at least delay that kind of development in a conversation, in an email exchange you can get there very, very quickly.

ALEXANDER: I think you said in your paper that you were comparing internet communications to dreams.

SULKOWICZ: Well my comparison to dreams was a loose one. I think the main point I was trying to make in drawing that parallel was to the kind of loosening of logical boundaries that you see certainly in dream material and in emails too. People really let it hang out in their dreams and they let it hang out in their email. People say a lot of what they‟re thinking, and some of what they wish they were only thinking but not saying.

ALEXANDER: You talked about some psychoanalytic theories of child development which also ran parallel, you felt, to the phenomenon of the internet. I was wondering if you could elaborate on that.

SULKOWICZ: Sure, there are a number of things that I was trying to illustrate in the paper. One is the notion of instant gratification. I think that may be a good place to start just because it‟s the most obvious. With email and the internet more generally, this relates not just to email but to the use of the web. There is a sense that you can get something very quickly that would ordinarily take more time, and that‟s a response from another human being. If you write a letter it takes a couple days to get there at the very least, and a few more for them to respond etc. In an email you can write a fairly detailed email and get a response very quickly. Part of the culture of email, I should also add, is one that values and reinforces the notion of responding very quickly.

Instant gratification goes far beyond how long it takes to get an email response. I think instant gratification also applies to other phenomenon such as shopping on the internet, or some of the services at least here in New York City. I assume these services exist in most major cities around the country that promise to deliver just about whatever you want in a very short period of time, even an hour. There‟s one service here that claims to have access to virtually everything; I

31 don‟t know if that‟s ever been tested as to how true that is, but certainly the kinds of things that you may have to put on your coat for and go for a drive or a walk to get. You just type it in, and of course add in your credit card information, and then supposedly, within an hour, it‟s there. So those people who have difficulty for instance delaying gratification, and there are certain kinds of personalities for whom that‟s very difficult certainly find a lot of gratification and pleasure in using the internet because they don‟t have to wait very long.

ALEXANDER: As we said a few minutes ago, I think the fact that it‟s also such an evocative experience, in terms of the lack of real visual cues, makes it is much easier to have fantasies, both positive and negative kind of fantasies.

SULKOWICZ: Well that‟s right. I‟m glad you put it that way because that actually relates to your question earlier about the connection to dreaming, because one thing we know about dreams is that dreams are quite complex. I don‟t mean to cover the field in talking about dreams, but one aspect of dreams is the idea that Freud initiated--wish fulfillment. Wishes are often expressed and fulfilled in a dream, wishes that in real life, or waking life I should say, are difficult to fulfill, if not impossible.

A classic example is a child‟s dream of a child who goes to bed hungry and then dreams of eating something. In a way that dream preserves the child‟s sleep, because it allows the child to sleep a bit longer. Of course the child wakes up and is still hungry, it does need to eat. But there is a similarity of the idea of wish fulfillment in dreams and wish fulfillment in the internet: you have this, not exactly blank screen, but it‟s still a screen - a kind of impersonal object facing you. You type in what you want, and you get it. It‟s kind of remarkable.

ALEXANDER: Well I‟d like to move to the topic of longer term, psychoanalytically oriented work on the internet. The common line that I‟ve heard the most so far is that virtual therapy should only be done as a type of brief treatment. I do not mean crisis intervention because that can be too risky, but some sort of brief interventions. I wanted to talk with you about it because I got the impression from your paper that this is an area where there could be an application.

SULKOWICZ: I would start by saying that I‟m a big believer in not only the usefulness of psychotherapy and psychoanalysis, but in the usefulness of that being conducted with both people being in the same room together. I think there is a lot to be learned in psychotherapy from the way the patient or client experiences the therapist in person. You don‟t have that when you‟re communicating via email for the reasons we talked about earlier. So that‟s my first caveat about the idea of conducting therapy on the internet--you lose out on the crucial aspect of the human interaction.

On the other hand, I‟m a fan of keeping an open mind to the possibility of using new technologies in creative ways, perhaps to reaching out to people who are reluctant to seek face- to-face traditional consultations or therapies. Psychoanalysis per se of course is a treatment that is very appropriate for some patients, but the vast majority of patients are not going to be in psychoanalysis. They‟re going to be in some other kind of less intensive psychotherapy in which

32 typically the two participants are going to be facing each other in the room, sitting in opposite chairs. But your point is well taken about that.

First, I‟ll express my concern, and then I‟ll express some thoughts I have about how I wouldn‟t rule it out. The concern is that doing an entire therapy over the internet is on the one hand going to appeal to people who have difficulty with intimacy. It is the intimacy that comes with being in the same room as another person and talking about very personal things. So if you‟re going to do an entire therapy using some kind of electronic communication such as the internet, I think that it should only be done if the therapist is cogniscent of the pitfalls of that kind of communication and is ever mindful of how the patient may be using this form of communication defensively.

For me that‟s a crucial point, both because of the lack of physical immediacy with the patient and the time delays that might be inherent in using email. I would certainly be opposed to using this kind of communication with a patient, for example, who has different kind of crises - psychiatric, psychological, or otherwise. I certainly wouldn‟t want to try to conduct this kind of therapy with say a suicidal patient.

On the other hand, and there‟s always an “on the other hand,” let‟s say I am working with a more seriously disturbed patient who does become suicidal from time to time. If I‟m meeting with that person twice a week, but in between sessions the patient finds it useful to now and then send me a brief email, I might be welcoming of that.

ALEXANDER: You know it occurs to me that with the kind of contract you try to establish with a suicidal patient when you‟re working with him or her, this would be something that would be terrific to include. In addition to the couple of sessions a week, there would be daily emails, once a day, twice a day. I could see how that could become sort of a wonderful adjunct and very reassuring to everybody.

SULKOWICZ: Yes, I think that‟s right. It would be similar to setting a boundary with a patient in terms of phone calls. Certainly with a sicker patient I would never want to say, “Look you can never contact me within sessions.” Just as you might allow a patient to contact you between sessions by calling you on the phone and leaving you an answering machine message for instance, it might even be better to encourage some patients to do that in an email. For one thing, it encourages these patients who have a great deal of trouble sometimes verbalizing their emotions to actually take a bit more time and to more carefully think about what they are feeling and put it into words on paper.

From the therapist‟s side it might also be more practical too, in the sense it might be less intrusive to receive an email that you can respond to rather than a phone call which takes more time to listen to and carries with it a greater kind of pressure to respond, especially in a more emergent situation. So I think these issues need to be thought through very carefully with each individual patient-- thought through in terms of setting up the arrangement of the therapy and

33 thought through in terms of meaning to each patient of how they choose to communicate with you.

ALEXANDER: Well, let‟s say you were “seeing somebody” through the email and you wanted to know what it meant to them. Would you think that could be something you could just ask?

SULKOWICZ: Absolutely, just as in a traditional psychotherapy where everything is potentially grist for the mill -- and that includes, of course, the way the patient relates to the therapist -- I don‟t see why you couldn‟t inquire similarly regarding a patient‟s preference for email. I might say to a patient, “Gee I notice that you feel freer communicating certain kinds of thoughts to me in an email message as opposed to when we talk on the phone or meet in the office. Do you have any ideas about why that might be?” This is a fairly simple kind of question reflecting your observation back to the patient and trying to engage his or her curiosity about it.

ALEXANDER: How do you think a transference would develop and be managed?

SULKOWICZ: Well I think transference develops no matter what you do. I think that certainly the use of an online form of communication will have some effects on the transference. My main concern is that it will be used as a defense against the intimacy that ordinarily develops.

ALEXANDER: But yet there is another kind of intimacy. Where is the “no intimacy” if the patient is expressing himself much more openly and deeply in a written communication than he would be face-to-face?

SULKOWICZ: I think that‟s a good question. I would say it‟s a double edged sword. If the patient is expressing himself more intimately and openly in the email, I would say that yes the patient is really speaking very freely to me and there‟s an intense process going on here. But I think it would also be crucial to then include--at some point in the course of the therapy--some attention to why that is. In other words, why is it that the use of email facilitates what would be otherwise very difficult for the patient? Hopefully if you‟re trying to help the patient with issues of intimacy in his life, you would ideally like the patient to develop the capacity for true intimacy. That is intimacy, as I would define it anyway, with another human being face- to-face.

ALEXANDER: You write in your paper that, and this is very important I think, “The more you study telephone and real-time internet communications as well as email exchanges, the more you learn to read nuance, affective shifts, defensive ploys, and slips of the „fingers.‟” I wonder what it is that you do? How do you learn to read nuance and affective shifts and everything? Is that just getting to know the person who is writing and his way of speaking through writing?

SULKOWICZ: Well, that would be one way to do it, absolutely, and I think that‟s an important thing. I think every patient communicates differently and any therapist knows that part of the therapeutic process is learning the patient‟s language, really.

Here is a more specific example I could give you. Let‟s say you‟re communicating via email

34 with a patient and the patient is talking about a situation that occurred at work. She is saying how angry she is with their boss: “My boss did this to me and I felt furious and I really had thoughts about wanting to start yelling at him.” You‟re reading this in the email and then the next sentence is, “I saw a great movie last night and it was really funny.” And then the patient goes on to talk about how funny the movie was, or a wonderful dinner they had or something pleasurable, something that doesn‟t really sound conflicted at all.

Well I might, if I‟m thinking about his dynamically, I might look at that email and say, “Gee the patient was just talking about how furious she was and describing in some detail not only how angry she was but what she was fantasizing doing with those angry feelings directed at her boss. Then all of a sudden there was this dramatic change in subject. She goes from talking about how angry she is and wanting to yell at her boss to something very pleasant and really moving away from the affect of anger.”

It‟s beautiful seeing that in an email, because it‟s like having a transcript of the psychotherapy session that you can then show the patient. You can say, “Gee, looks like you were coming up against some strong angry feelings there and then suddenly, you moved away from them. Do you have any idea why you might have done that?” You have the evidence there right in front of you and you can talk about it together. It may be that the patient started to get frightened of the intensity of her angry feelings, or concerned about what you might be thinking of her, and so she shifted away to something neutral or pleasant like a good dinner. So that would be an example of being able to track what I‟m calling “an affective shift” in an email.

ALEXANDER: I think there‟d be so many things that you could track like that. It would be so much plainer in a way.

SULKOWICZ: That‟s right. I referred to something else in my paper. I think you can also get data from patients‟ email about the way they view themselves and aspects of their self-esteem. The way people write is very revealing--if they‟re self-deprecating or highly self-critical of the way they write or of the things they say. I think that that‟s also data that you can fairly readily garner in an email and you can reflect it back to the patient. Again, one of the wonderful things about it is the data that becomes tangible and mutually observable to use in a very real way.

ALEXANDER: It‟s important that you say mutually observable, because much of the critique of online therapy is that things aren‟t observable in the same way. Yet there are other ways.

SULKOWICZ: That‟s right; it‟s a different kind of observation. You can‟t observe the patient if you‟re doing it online with the exception of using a television kind of hookup--a video hookup. The point is that while you lose out generally on some kinds of observation you have the ability to observe written data, and that can be very valuable.

ALEXANDER: Could you tell us please about the work you did at the website of the psychoanalytic consulting group?

SULKOWICZ: What we were trying to do there was to take advantage of the very features of internet communication that you and I have been talking about and create a website that was designed to reach out to people out there in cyberspace who were, for whatever reasons, hesitant to seek more traditional psychotherapy. We assumed, and I think we assumed correctly, that there were a lot of people who may have entertained the idea of seeking psychotherapy at one time or another in their lives but had been put off, whether it was by virtue of their own shame about seeking it, or concerns about stigma or cost, or simply more pragmatic concerns about the availability of component therapists nearby.

Whatever their reasons, we were hoping to offer something to them that wasn‟t an offer of ongoing psychotherapy but a taste of how a psychodynamically trained psychotherapist might begin to think about their problems. Really, the idea was to make this process less threatening and to give them a taste of what it was like, and then hopefully help them find a referral nearby if they were interested in going further with what they started with us.

The way that it worked was kind of an interesting series of things. It was a fee-for-service website so people were asked to pay a fee for what amounted to a series of exchanges with one of the people on our team. The way it began was this: first they would give us some basic demographic information, their names and addresses and so forth. The second part of it was they were asked to describe what area of concern they had or what they were curious about. Then the third area, which I thought was the most interesting, was that we instructed the user on essentially “free associating” by email. Essentially what that involved is to start with their area of concern--their so-called chief complaint-- and to start typing and to never use the delete key. To just start writing whatever came to their minds about their area of concern or interest. And when they felt they had said enough, to send it to us.

What we would do is read their email, and read it in a way that I was describing earlier. That was the example I gave with the person who was angry and then shifted away from her anger into talking about something pleasant. We would take a look at it in a very close, “process” way, looking for areas that we thought revealed areas of conflict, or areas where somebody would feel very free to talk about (write about) something, or any other aspects of the dynamics of their concerns that we could derive from such a brief communication.

What we found was that people were extraordinarily open with us in these emails, and what we tried to do was--in a humane and thoughtful way--reflect back some of our own impressions of what their concerns might be about. We would not go too deep, because frankly we didn‟t know the person, and we didn‟t want to do anything that might frighten them or make them worse. But in a fairly straightforward way, we used plain language, no technical jargon, and gave them some ideas about how we as therapists might begin to think about their problem. We were hoping to try to engage them in an intriguing way and it tended to work.

So they would send us their first email, we would send one back, they would respond to our comments and then we would respond back once more. Those were the four exchanges, and at the end of that was the idea that if they were interested in going further, we would find

36 somebody who would be reasonably like-minded-- such as the therapist who was responding-- and they could continue with that therapist in a more ongoing way. That‟s the gist of what we were trying to do.

Given that we never see these people face to face, we did make a lot of disclaimers on the website before allowing anyone to start. For example, if somebody had been diagnosed as having a major psychological problem or psychiatric illness, was on any kind of psychiatric medication, or even was in psychotherapy with somebody, they should either not use our service, or at the very least discuss it with their therapist beforehand. We certainly didn‟t want to interfere in anybody‟s ongoing therapy. So we were trying to offer a service, but we were also trying to do no harm.

ALEXANDER: Dr. Sulkowicz, is there anything we didn‟t cover that you want to mention or any additional thoughts for us?

SULKOWICZ: I could talk about this on and on because it‟s an area that really interests me. I‟m really fascinated by the interface between psychology and the use of new technology. The only thing I would just emphasize is that while we need to be careful in doing no harm and first and foremost we need to be watchful, that doesn‟t preclude our exploring these new ways of communication. Doing psychotherapy is about communication. The traditional ways of talking work very, very well, but we shouldn‟t rule out at least adding these new ways of communication to our skills in terms of trying to help people.

ALEXANDER: Thank you Dr. Sulkowicz, very, very much.

SULKOWICZ: It‟s my pleasure. It really has been fun talking to you.

This concludes On Good Authority‟s interview with Dr. Kerry Sulkowicz. We hope you learned from this interview and that you enjoyed it. Listeners interested in contacting Dr Sulkowicz may email him at [email protected].

I must say here that the opinions expressed by our speakers are theirs alone and do not necessarily reflect the opinion of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.

ONLINE THERAPY: CLINICAL AND ETHICAL ISSUES

Interview #4: “Ethical Issues”

KATHLEEN MURPHY, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD (Edited slightly for readability)

Kathleen Murphy, Ph.D. 1920 Waukegan Road #4 Glenview, IL 60025 847-729-3034 E-mail: [email protected]

Welcome to On Good Authority. I‟m Barbara Alexander. You are listening to or reading Interview #4 from our program “Online Therapy.

Before we go a single step further in our look at Online Therapy, we must address the serious legal and ethical concerns it raises. You‟ve heard three interviews so far ranging from the, “It could happen,” to the “enthusiastic embracing” of online therapy. Now it‟s time to hear the problems, negatives, and real concerns of sensible people about it.

But a preface – there is a whole lot of really irrational, even hostile thinking about online therapy that surprises and distresses me – especially when it comes from professional organizations and regulatory boards. One person went so far as to compare the need of patients for online therapy with the need of some people for online pornography, saying “Just because they need it doesn‟t mean they should get it.”

This is exactly the kind of thinking that is not helpful. It is shortsighted, emotional, and infantilizes and insults patients. How could anyone equate people wanting help with people seeking pornography? There are lots of issues and lots of questions about online therapy, and all are best approached with cool heads; not with anxious biases.

I‟m going now to quickly highlight the concerns and problems, many of which were posed by another of our speakers in this program, Allen Siegel. In this interview, we will hear from Kathleen Murphy, who has spoken to us before about ethical issues. 38

First, a few of the many clinical concerns for the therapist:

1. The opportunity for misunderstandings is enormous because it is a written medium of communication and both readers are deprived of the non-verbal elements of communication which, as our speaker Dr Allen Siegel wrote, “are the face and voice that give music to words. The meaning of so many things are carried in the music, not the words.”

2. We are not trained to diagnose or treat people using paragraphs or online language.

3. The opportunity for exploitation is enormous (but then, the same can be said for face to face treatment)

4. People may be using online therapy as a substitute for traditional face-to-face therapy in a defensive way.

5. Online Therapy cannot ensure the true identity of patients who may represent themselves

6. It may delay or interfere with services because of incompatible computer equipment and computer crashes.

7. Does Online Therapy water down our professional image and reduce us to Ann Landers?

Then, some of the many legal concerns for the clinician:

1. Here‟s one of the biggest concerns–the one most often posed: if a licensee is licensed to practice in one state and the client resides in another, and is this appropriate under one‟s license?

2. Professional Associations and regulatory bodies all over the country are struggling to restrict the Online Therapy movement. Check regularly with yours if you are considering doing Online Therapy since rules and positions change constantly.

3. Confidentiality is not always insured. This opens the practitioner to high risk of allegations of malpractice based on breach of confidentiality.

4. How does the therapist know the capacity of the client to contract? What if there a disability because of age, mental condition, or guardianship?

5. As yet there are no “generally accepted methods” for email therapy, no clinical guidelines, no practice standards, no documentation requirements, little research, and only beginning theory. What constitutes the record, progress notes, or clinical file? Does every email

39 and instant message have to be printed out? Is email therapy covered by malpractice insurance? There is no way to ensure that providers have the appropriate education, training, and credentials to provide the service.

6. If we say that we are doing “coaching” or “education” or “mentoring,” does that safeguard us from malpractice? As far as I know the answer to this is a resounding “NO”. If you are involved in a professional relationship with a client, it doesn‟t matter what you call it, or what you call yourself. You are still practicing under your license and you will be handled under the standards of care of your profession. In other words, you will be sued at the level of your highest professional license!

We need our professional organizations and regulatory boards to be developing these guidelines and promoting research to answer these questions, not taking “politically correct” and knee-jerk negative stances.

Now to our speaker.

Dr. Kathleen Murphy has served on the NASW Committee on Inquiry in Illinois since 1985 and is a recent past chair. She served on the Ethics Advisory Group for NASW president Ann Abbott at the national office and is a frequent speaker on the topic of ethical issues in clinical practice. She received her Ph.D. in social work from the University of Illinois Jane Addams School of Social Work and is on the faculty of the Institute for Clinical Social Work, as well as being a visiting lecturer for Loyola University School of Social Work. In addition to her private practice and her workshops on ethical issues, she has published on the topics of home care with families, and addictions.

ALEXANDER: Dr. Murphy, to your knowledge have ethical codes kept up with these new developments for Online Therapy?

MURPHY: It certainly is my impression at this juncture than none of the mainstream professional organizations have been able to come up with any substantial standards that are directly related to the provision of mental health services online. I know the American Psychological Association is actively working on it and has a document online about confidentiality. The NASW has a vague reference in their existing code about electronic transmission of information, and I‟m not sure whether or not they are developing standards, although I hope so.

I have found two substantial documents. One is online by the International Society for Mental Health Online and it has some suggested principles for online provision of mental health. This means that it is not yet a document that people can be held accountable to. The second is by the National Board of Certified Counselors and its standards are for the ethical practice of web counseling that their membership actually can be held accountable either.

ALEXANDER: In the absence of these things, how are we to determine what is ethical behavior?

MURPHY: The issues that I see in and around the internet are in two general areas. The first area relates to our ethical obligations as mental health professionals with regard to the actual information that‟s available on the internet. Then the second broad arena is the actual provision of mental health services using the internet as the meeting place or as the “office.”

Now when I first started looking into mental health services and the use of computers, I was concerned--and I think most people were--about confidentiality on the internet as it relates to the transfer of information via email and chat rooms and message boards and things like that. However, I think with encryption built into so many of these software programs and numerous other available safeguards, I certainly am less concerned about confidentiality per se. I think people are more and more sophisticated in terms of figuring out how to protect confidentiality on the internet. It‟s an important ethical consideration, but I think that‟s the least of our worries at this particular juncture, as I think most people have sort of figured that one out. I think what is more of an issue is how we use the computer that creates ethical issues.

ALEXANDER: Are we as therapists under any obligation to encrypt?

MURPHY: No, I don‟t think we are. In fact I think encryption programs are very awkward and very cumbersome and overkill in terms of upholding our ethical responsibility relative to confidentiality. I think providers need to be very aware of the fact that when they‟re in an agency setting or in a network setting that other people may have access to confidential records, and need to do whatever needs to be done in terms of safeguarding the confidentiality of records from the casual observer. But again, for the most part people are linked up to their direct office, or there is the situation where they‟re the only one who has access to the information. There certainly is no requirement to encrypt, and in fact encryption is a pain in the neck - clinically and ethical.

ALEXANDER: Well, let‟s go on then to your main concerns.

MURPHY: Ok, I want to put the internet in a professional context just for a minute here. For decades different mental health professions have debated what a “legitimate” field of practice is. Child and family welfare, social policy administration, medical and psychiatric settings, schools -- all of those are determined by all mental health professions to be legitimate field of practice, without question. Over the decades, as different needs with different populations have emerged, forensic mental health, criminal justice, child abuse, geriatrics, death and dying etc., have emerged as fields of practice or as practice specializations. Even the private practice of mental health, which has been around for decades, is actually one of the newer accepted specializations or fields of practice for mental health providers.

I think mental health providers have generally come to some agreement that mental health

41 services can be provided almost anywhere within reason, and with almost anyone, as long as certain traditional values such as autonomy, confidentiality, informed consent, self determination, things like that are maintained.

The internet or the world of cyberspace is, as best I can tell, a truly new and emerging contender as a field of practice, but the question legitimately can be raised: Can a virtual world be a field of practice? I don‟t actually know the answer to that question because I don‟t actually know how those things are decided, but at the very least, I think we need to think about and talk about ethics and clinical issues on the internet. I think we need to consider the internet or this virtual world of cyberspace to be a field of practice because it‟s already there effectively as such. It‟s up to whatever the powers that be to determine that it is. But for right now, I think we need to think of it as a field of practice.

Concurrent with that, over the many years of the development of mental health services, theories of mental health practice have long been subject to various different sorts of debate in terms of what is acceptable mental health theory. Those of us who are a little bit older can remember when the clinical debates were always about the varying degrees of Freud, or Ericson, or Kohut, Kernberg, and a host of other psychodynamic object- relations theorists in that theoretical mix. Then along came the behavioral, and the cognitive/behavioral, and the rational/emotive theories. And there was always that debate between the nuances of psychological theory and behavioral theory. More recently have come the body-mind theories and whether or not these things have validity in our practice as mental health professionals. So the question is no longer are you psychodynamic or are you behavioral? It‟s no longer even whether you are traditional or alternative in your approach as the aromatherapies and meditations and EMDR have gained in popularity and have taken over the far end of the spectrum.

We now add the internet, which poses the exact same challenges that behavioral theory offered to psychodynamic theory, and that alternative interventions offer over both of those previous, larger groups of theory. The internet challenges how we think about how we provide mental health service. So now the question is no longer “What‟s your theoretical orientation,” but whether or not you‟re online or offline or both. I think this is an important contextual piece that we need to be mindful of as we talk about ethics on the internet.

Now, the internet is available to us as a part of the context of a rapidly changing world. It is both a change agent in and of itself, and it comes as a result of changes in the way things are done. I think that‟s a legitimate contextual piece. The internet brings us closer than we have ever been to a vast amount of information about new and emerging everything; it is the ultimate library. With the click of a mouse button, we can have daily updates on everything, from the newest research on autism, to the latest drug trials that the FDA is doing, to whatever psycho-babble we want to look at. We can look up articles in obscure journals, mainstream journals, we can get articles in obscure languages and we can get them translated in seconds. Not only do we as professionals have access to that information but so do clients, and this is adult clients as well as child clients. I think that raises an extremely important ethical consideration for us as professionals.

ALEXANDER: Dr. Murphy, I‟m interested in your statement about the currency, the multitude and the amounts of information that are available on the internet. How accountable are we supposed to be for us to be current on all of these things?

MURPHY: Well I think that is sort of the crux of the matter in terms of how we will be held accountable. For me, the issue really became very poignant and very clear when I was working with a nine-year-old, third grader with an obsessive-compulsive disorder that was in the moderate to severe range. She was going to need medication in order to manage the symptoms. I talked with her and her parents already about obsessive-compulsive disorder. At the very next session with me, she showed up in the office with print-outs about obsessive disorder and treatments and different medications. And we sat there discussing all the information she had obtained from the internet, all by herself.

It became very clear to me at that point that not only did I need to hold myself accountable but my clients were going to hold me accountable, and rightfully so. I think as professionals we need to not just monitor ourselves but I think our professional organizations are going to have to come to grips with what is relevant information that we can rightfully, ethically, be held accountable for when we think about the fact that we have to stay current and relevant with emerging knowledge. It‟s a very important issue as we think about access to the internet. It has been my experience that there is no limit to the amount of information that we can access. I think that ethically this is a significant new challenge: how accountable must we be in order stay current in the information that is available on the internet?

Now, all professional codes of ethics, for all of the health providers that I‟m familiar with hold that the respective professional will be proficient in their professional practice, and “current with emerging knowledge.” Now, where it used to take years for new information to emerge in terms of being published in professional journals or professional books, research can now be published on the internet daily.

So this raises an important competency issue as well as an ethical concern: does the information on the internet truly qualify under our respective codes of ethics as emerging knowledge? And if it does, can we be held accountable for that emerging knowledge in terms of our moral obligations to clients? Our moral obligation is to stay current with--at the very least--our own areas of specialization. I think it does. So I think clinicians who avoid the internet are doing themselves and their clients an ethical disservice. These clinicians are potentially setting themselves up for peer review process or ethical concerns as well as some legal concerns down the road, although legal issues--in terms of the internet--are very mild at this point because this hasn‟t really been tested out. So I think this issue of emerging knowledge--as well as the knowledge available--is a very important arena for ethical consideration.

Another very important aspect of the information on the internet that I think we need to take into consideration is that there is no limit to the number of people that can be reached via the internet, especially compared to traditional methods of disseminating information. For example, Michael

Freeny is a couple‟s counselor in Florida, and he conducts sex and love chats three times a month on the internet. Now these chats draw from eight thousand to ten thousand participants at a session who ask questions which Mr. Freeny then answers or responds to online. Now these chats are just that--they‟re chats. They‟re not psychotherapy, but they offer an opportunity to educate thousands of people about a variety of issues in terms of his perspective related to love and commitment in marriage and sexual response or sexual desire problems and so forth.

Now this raises another very legitimate question of whether or not the internet does qualify as an appropriate mental health service arena. It also raises the question about the definition of a “client,” and how we think about providing ongoing (some people will call it, educational service) mental health service to thousands of people week after week, month after month. Now, he has obviously no control over who logs in or who doesn‟t log in to his individual chats. The only comparable thing we have in regular or “normal” practice is group therapy or support group type work. Now we don‟t think of eight-to- 10,000 people as falling into that definition, and I‟m not saying that it does, but I think being able to have this sort of intimate chat with ten people or 10,000 people raises an important ethical consideration. But I don‟t have the answers.

ALEXANDER: Dr. Murphy, if you think about, say, Dr. Laura on the radio where millions of people are listening, how is that different?

MURPHY: I don‟t know that it is effectively different. I think we need to think about all of that stuff in terms of our ethical responsibilities as professionals. I think there‟s a difference between the definition of--or how we seek to define--psycho-educational, or educational mental health and psychotherapy. When we start getting into the issue of talking with specific people about their problems online, the response to one person‟s question then goes to 10,000 people; I think it is something we need to think about. I‟m not saying it‟s inherently or ethically wrong, I don‟t know that it‟s inherently ethically right either. But I think these are the sorts of things that we need to think about when we look at what the capabilities of the internet might be.

ALEXANDER: Well some specific questions then Dr. Murphy. In face-to-face therapy, traditional Freudian psychoanalytically oriented work, you‟re supposed to listen for a long time until you know the person so well that what you would say would have real meaning. You‟re supposed to withhold comment. Now on the internet with email you are obliged, it seems to me, to say something right away and there‟s more danger that there‟s insufficient information on which you have to base any intervention or any message or any statement you might write.

MURPHY: Absolutely. I mean I think that‟s an important issue in terms of providing mental health services on the internet. More traditional clinicians are firm in their belief that psychotherapy, per se, cannot occur online, while others report conducting ongoing individual or group therapy online with good results. Now regarding that debate of the clinical and ethical pros and cons of E-therapy--or cyber-therapy vs. face-to-face therapy-- are those who offer a disclaimer saying that what‟s online is not psychotherapy. If you look at Martha Ainsworth‟s website. . .

ALEXANDER: Metanoia.

MURPHY: Yes, the website is an excellent consumer-driven and consumer-friendly website for the whole range of accessing mental health services. She‟s very clear that e-therapy is not psychotherapy.

Now I take issue with that for a variety of different reasons; I think those disclaimers are lame at best. I think if, on a very surface level, we‟re going to call it e-therapy, then we‟re equating it to psychotherapy. I think this raises huge issues regarding clinical and legal responsibility/liability in the event that something does go wrong. I think the disclaimers that it‟s not psychotherapy and that “clients” are really consumers, not clients, would not stand up. It does not stand up, I think, in terms of good clinical thinking or good ethical thinking. I don‟t know if it would hold up in a court of law. But I think if it‟s not therapy, then to call it therapy means that consumers are going to view themselves as clients.

That said, I think once we begin to provide professional service to people, certainly on an individual basis, we do enter into covenant relationship then that entitles them to the same level of professional and ethical responsibility that a face-to-face client has.

I‟m sure your other speakers have talked about some of the difficulties inherent in text-based communication, the lack of verbal and non-verbal cues. Obviously it lends itself to all different kinds of clinical issues and misinterpretation of communication, actually missed communication as well as different nuances of the developing relationship. There‟s certainly a lack of standard controls when you look at online therapy relative to safety issues: crisis intervention, child abuse, spouse abuse, suicide, and homicide -- because of the anonymous situation.

So that raises a whole host of other clinical and ethical issues related to the best interest of the client. But there are, as you mentioned, benefits to the anonymous client. I think some clients are more likely to access help if they are anonymous, but I think the minus side of that is huge. From my perspective, I think ethically that the minuses outweigh the pluses when we‟re talking about a totally anonymous client. With anonymity it is easier for clients as well as providers to misrepresent themselves--not that this doesn‟t happen or can‟t happen in face-to-face contact-- but it‟s certainly less likely to occur in-person than online. More importantly, it‟s less likely to happen as frequently in person as it is online. This means that online, deceptive, fraudulent, or unethical practitioners can use, abuse and act in a fraudulent way and misrepresent themselves to large quantities of client that they would not have access to an office or face-to-face situation. I think that in-and-of-itself is something that the various professions need to consider relative to standards of practice and how we go about monitoring online services.

Similarly, there is really nothing that stops the unethical practitioner from bilking the public or from being voyeuristic or abusive online, and I don‟t know how we monitor that or how we prevent that from happening, but I think opening that door in a substantial way to providing online therapy in an anonymous way is potentially very dangerous and I think we, as professionals, need to be aware of that.

ALEXANDER: Well, Dr. Murphy, what about the notion of caveat emptor--let the buyer beware. The potential client does have an obligation to protect himself too.

MURPHY: Yes, absolutely. But I think all of our professional standards of practice and codes of ethics are very clear that there‟s a power difference between the mental health provider and the client. Even when a mental health provider is a client, the client has some rights that are built in, protecting him simply because he is a client. And by virtue of being a client, there is some determination that the individual or that client system needs some protection. And right now they are unprotected on the internet.

ALEXANDER: That is, by the way, what I was hoping you would remind us about

MURPHY: It‟s extremely important that we be mindful of the fact that if there aren‟t ethical practitioners providing service on the internet, that void is going to be filled with unethical practitioners. I‟m not saying that we shouldn‟t be there, but I think we need to be very mindful of being there and very mindful of the fact that the power differential doesn‟t change, effectively.

ALEXANDER: That‟s a very important ethical principal. I would like to go back to something you said earlier. Let‟s say we are not calling what we do “online therapy” (let‟s say we call it “coaching”), and let‟s say we‟re not calling the patient “patients” or “clients,” we‟re calling them “customers” or “consumers.” That doesn‟t really change what we‟re doing and if it‟s no different, let‟s say, from the free advice or quick advice that you may get from Ann Landers or Dr. Laura, why then is there any obligation to pay for it?

MURPHY: I think if we‟re licensed professionals online then we need to be paid for the service that we provide, but we need to be mindful of the professional service that we do provide. One of the disclaimers I see all the time on different websites is that no diagnosis takes place online because diagnosis needs to take place in the presence of the individual. That may be, but if somebody has the signs of agoraphobia, for example, and establishes an online relationship with somebody who specialized in anxiety disorders, it‟s absurd to say that no diagnosis has taken place.

If it looks like a duck and walks like a duck and quacks like a duck, then the chances are very good that it is a duck. I would say that‟s true about diagnosis and that‟s true about psychotherapy online. If therapists are providing counseling, coaching, or Ann Landers-advice online, then they are providing mental health services, and that can and should be covered by traditional standards of practice and traditional codes of ethics. And I think professionals need to act that way and respond that way.

ALEXANDER: So even if they‟re calling it something else, if they‟re charging for it, it is still…

MURPHY: Whether or not you‟re charging for it, I think we have a professional

46 responsibility. If somebody doesn‟t charge a client for advice that they give over the phone or in the office, that doesn‟t exclude them from their professional responsibility. As abhorrent as it is when we find out practitioners who have had sex with clients in the office and then charge them for that session, it‟s no different than not charging them and having sex in the office. We have an ethical responsibility where we have an ethical responsibility; where there‟s a professional relationship there is that ethical responsibility and clinical responsibility.

I think ethically, clients online, no matter what we call them, have a right to the same best practice service and professional service that a face-to-face client is entitled to, and that involves all of the inherent protections relevant to safety issues, as well as autonomy and self- determination and the time and attention of the therapist. And yes, I think people should be paid for their professional service. I don‟t have any problems with that, but being paid for me is not the determining factor of whether or not a professional relationship exists.

That said, and I know it sounds like I‟m more negative on this than I probably am, I think in terms of defining the client, I absolutely have no problem with providing services on the internet to existing clients. I think it is an important adjunct to the service that we do provide. I think using email for appointments and setting an agenda, or passing on communication from a teacher or another source are things that we can ethically do. I think obviously person-to-person is more secure in terms of confidentiality, but sometimes that‟s not practical in this day and age all the time. In fact, I have to say it‟s probably more secure in terms of confidentiality to make appointments and send documents and information via email than it is on a cell phone, which is not confidential.

I think the issue of basic transfer of information is not an issue so much of whether we ethically can do it; it‟s whether or not we need to do it. I really see no reason for clients under normal circumstances to use the internet instead of the telephone, for example. I think it can get prohibitive clinically in terms of the amount of information clinicians can receive from various clients. Via the internet, people can forward all kinds of things and you end up getting bogged down in details that they wouldn‟t necessarily have given to you in the clinical session. So that‟s more of the clinical considerations; I think it‟s ethically feasible but clinically I don‟t think it‟s necessary.

However, I see for example, and have seen for years - kids. Some of those kids are college aged and I‟ve had long standing relationships with these kids. Over time I‟ve conducted various phone sessions with them when they‟re at school and office sessions when they‟re in town. These kids will periodically email me at two or three o‟clock in the morning regarding quick questions or things that are bothering them, items for our agenda next time we meet, or scheduling sessions. This is very appropriate. Ethically, clinically, I don‟t see that there‟s an ethical problem with even doing a fair amount of clinical communication via email with an existing client. There‟s a relationship there. Especially for young people, it is the way they communicate with family and friends; it‟s a viable way to stay in touch with their therapist; and it‟s an adjunct to the existing, and supporting of the maintenance of the relationship. So I don‟t have a problem with that when kids are overseas, or when adult clients are overseas. It‟s a way

47 to communicate with people. And again, as long as both parties are aware of confidentiality issues when somebody is communicating from a remote location, I think it serves a very important and supportive maintenance of the relationship. I‟m very, very pro the use of the internet in that regard.

On the flip side of that, I have a real difficult time with the notion of providing online therapy with clients where there has not been and there is not going to be an in-person relationship. I have difficulty ethically envisioning how one could clinically justify treatment intervention with someone who you‟ve never met or talked with and are not going to. I just can‟t fathom a way in which clinically it would be in the best interest of the client. For the client to be so anonymous let alone the therapist to be so anonymous, doesn‟t sit with my theoretical model. I‟m also not aware of any theoretical model that it does fit with in terms of how we think change happens in relationships. Now, I‟m not against psycho-educational information, meaning I think there can be a lot of information transmitted to people that‟s not part of the therapy relationship, per se, although we use so much educational information in the therapeutic relationship, I think sometimes the distinction is difficult and I‟m very cautious about that sort of thing.

With that said I think other people may be able to sort that out for themselves in terms of their theoretical model. But for me, it seems way too far out of the whole mental health theory loop, for me to consider a totally anonymous therapy as clinically or ethically appropriate. I‟m just not aware of any theoretical model in mental health that allows us to have that relationship be so remote. Which then also raises all the safety concerns around suicide and things like that, child abuse, domestic violence, misdiagnoses, giving information to somebody or making recommendations to somebody that we don‟t know, or somebody‟s deluding us or them. Whatever it is, can it be done clinically? I suppose it can be done but I don‟t think it should be done. I think we have fast food and we have immediate gratification of almost everything, but I don‟t think it‟s in the best interest of mental health consumers to put the provision of mental health on the fast food track.

Now that said, because I work with disabled clients and their kids, I have many clients who find many support groups online. As a clinician I find those to be a very important service to clients and I help them sort out good consumer technique in terms of how to read and use other resources online. Clients come to me all the time with information they‟ve picked up online, and I don‟t hesitate to look up this information with clients, and for clients and at the recommendation of clients. We sort out what makes sense and what doesn‟t make sense in terms of how they can be educated consumers. So there‟s lots of mental health information available online which I think is helpful to clients.

ALEXANDER: Let‟s move to the subject of payment. The issue, as we have talked about previously, has to do with being paid for service ahead of the service delivery, and you have mentioned some things in the codes that you feel are relevant.

MURPHY: All of the professional codes as I read them are very clear that fees are to be collected that are commensurate with the service that has been provided. This means that

48 payment for service is after the fact. In fact, I don‟t know anywhere where we pay the doctor or the therapist upfront. Now some clients do come into session and put the check on the table, but the bottom line is that I find this sort of collecting our fees upfront, people purchasing packets of emails very questionable.

ALEXANDER: Well when you go to a doctor, for instance, the first person that you see is the office secretary or the person handling the claims. The first thing they get from you is your insurance card so they can make a copy of it so they know ahead of time that they are going to be paid. They don‟t collect it until the service it rendered, they don‟t bill for it, but they know that they‟re going to be paid. And this just doesn‟t happen so much in mental health, I don‟t think. They have the assurance that they‟re going to get paid. So why can‟t we mental health practitioners get the same assurance in some kind of way, or get the payment?

MURPHY: I don‟t think it‟s a matter of “can‟t.” Every practitioner, especially private practice practitioners screen clients upfront in terms of the ability to pay. That‟s not the issue. I think the notion of prepaying for a package of emails is contrary to standard mental health practice, where the fees are collected at the end of the service provided. And I don‟t mean at the total end of the service for an ongoing process, but I mean at the end of a session by session or at the end of the month.

I raise that issue because of my concern that providers are getting online because it is a place to make money. I certainly have no qualms and no problem with mental health practitioners making money. I don‟t have that concern, but I think people are doing online stuff because it‟s easy--easier anyway. There are fewer standards, fewer cross-checks, much less peer review, much easier access to clients with less hassle, if you will, in terms of screening people. There‟s less legal liability, at least at this juncture, because of the geographics involved with work on the internet. I think it looks to me and smells to me often like it is more of a money-making proposition than a provision of mental health service.

ALEXANDER: As I look in the suggested ethical principles of the International Society for Mental Health Online, there is not a single mention about fees and collection fees. Was there anything in the NBCC code?

MURPHY: There is the, “make sure you discuss,” which is standard in the codes of ethics: Make sure you discuss with clients what the fees are and what the payments will be. We always do this in the first session with every client. So it‟s not the discussion of it that I have an issue with; it‟s the “give me your credit card number upfront” (or your check, or your draft, but most of it‟s done by credit card). I think we have an ethical obligation to consider whether it‟s in the best interest of clients, or at least to help clients think about whether it‟s in their best interest to rack up ongoing therapy bills to their credit card, which adds to their consumer debt. Not that people go into debt to pay for therapy, that‟s not my issue.

My issue is that we think it through using ethical standards and not only business practice standards. So I don‟t want people to get ripped off or professionals to get ripped off. I think we

49 need to get paid, and can be and should rightfully be paid for the service that we provide, but I think we need to think about it in terms of ethical standards. You know for decades we‟ve debated that in private practice and in agency practice: how to collect fees, when to talk about fees, who should collect fees. I don‟t see that dialogue happening on the internet and I don‟t think it needs to be discussed ad nauseum but I think it does need to be discussed.

ALEXANDER: Dr. Murphy, have we in this brief period of time been able to highlight your list of ethical concerns here?

MURPHY: The other one that we haven‟t hit on is the issue of the geography, or the lack of it on the internet. As a licensed practitioner in Illinois, I cannot move to California and be a licensed social worker, but on the internet it doesn‟t matter where I‟m licensed. I can practice in Istanbul if I want to. We haven‟t contended with, or professional organizations haven‟t contended with, “where does the practice actually take place?” If I‟m a provider in Illinois and I have a client in France, do we work with standards in France or do we work with standards of practice in Illinois? This raises huge ethical concerns as well as legal concerns.

The other ethical issue I want to raise is competency. In no area of mental health practice do we see the opportunity for absolute novices to be providing service without supervision, without consultation, like we do on the internet. All the professional codes of ethics refer to the requirements for people to be competent to do what they‟re doing and/or to receive appropriate supervision and consultation if they‟re entering into an arena that they don‟t know or that they‟re unfamiliar with. I‟m not against people engaging in novel practice areas, but I think we need to be very mindful of the fact that people are not necessarily competent to practice online. I think this means not only that people need to be grounded in their own professional theory and practice, they need to be reasonable offline practitioners before they go online because the clinical nuances online are much more complicated, and more complex.

But what I think people are thinking is that it‟s much simpler and it‟s less complex online. I think that negates the whole concept of human functioning and what‟s involved with being a change agent. The absolute bottom line is that all of this is new and emerging; I think it‟s exciting. I think it‟s challenging for us as professionals to think about and ask not just the clinical questions but the ethical questions. And to dialogue on an ongoing basis about--not so much what we can do (because it‟s rapidly appearing that we can do almost anything online), it‟s what we should do. What is our moral responsibility to do relative to the best interest of clients, and protection of the public? That‟s always the bottom line for me--that we use reasonable ethical decision making.

ALEXANDER: Dr. Murphy, if I had to define what your mantra is, it‟s something along the lines of, “It‟s not what we can do, it‟s what we should do” - and I love it. Thank you again.

MURPHY: You‟re welcome.

This concludes our interview with Dr. Kathleen Murphy. We hope you learned from it and that you enjoyed it. Listeners interested in contact Dr. Murphy may email her at [email protected].

ONLINE THERAPY: CLINICAL and ETHICAL ISSUES

Interview #5: “Online Supervision”

ALLEN SIEGEL, M.D.

Interviewed by Barbara Alexander, LCSW, BCD (Edited slightly for readability)

Allen Siegel, M.D. 122 S. Michigan Chicago, IL 60603 312-583-0905 E-mail: [email protected]

Welcome to On Good Authority. I‟m Barbara Alexander. You are listening to or reading interview #5 from On Good Authority‟s program on “Online Therapy.”

The self psychology community is increasingly an international one, yet training in the theory and practice of these ideas is rarely available outside the USA. Access to this training is usually obtained only by reading and by travel to conferences in the states or to international self psychology conferences. Many countries, especially those outside the western world lack an integrated and coherent curriculum for training and knowledgeable supervision in the theory and practice of psychotherapy, but the desire for this knowledge in supervision is present and growing.

Now as we all know, nature abhors a vacuum, hence the internet, where one can learn and gain access to just about any kind of information. But how to supervise the learning of psychotherapy at a distance?

Online supervision is emerging as a very promising online activity. A few brave and creative students and psychotherapists have developed beginning models in this distance learning. Actually it is too soon to call their work “models”; it‟s more like collections of experiences in supervision through email. I think you will find this work very exciting and filled with possibility for the teaching and learning of psychotherapy.

Our speaker, Dr. Allen Siegel, an American Psychoanalyst and Self-Psychologist, with Eva Maria Topal, a psychotherapist in Germany have moved gently and thoughtfully into this vacuum and began what Dr. Siegel has called “E-Supervision.” Here he discusses his work with her and how his work with a group of psychiatrists in Turkey developed.

Dr. Siegel is a member of the faculty of the Chicago Institute for Psychoanalysis, Chair of the Kohut Memorial Fund, a member of the International Council of Psychoanalytic Self Psychology, and editor of their newsletter. He is also Assistant Professor in the Dept. of Psychiatry at Rush College of Medicine. He is the author of the book, Heinz Kohut and the Psychology of the Self, as well as several related articles and book reviews.

ALEXANDER: Dr. Siegel, how did you happen to begin doing online supervision?

SIEGEL: Well, the way it began was that [psychoanalyst] Ernie Wolf was at a conference in Germany, in Dreis, Germany, and after the conference a woman there, an analyst, who is interested in self-psychology, asked him if he knew of anyone who would be interested in corresponding with her in terms of supervision. He recommended me to her. We got in touch. We began by using a fax because neither of us when we started had the equipment sophisticated enough to handle the email at that time. After a little while we got the equipment and moved over to doing it by email. We had totaled about 140-150 letters back and forth in our correspondence.

ALEXANDER: And this went on over how long a period?

SIEGEL: Close to two years. Actually it worked out that we had a letter about every week, maybe it was a year and half, something like that.

ALEXANDER: Did you make actual appointments? In other words, would you say, “I will get something to you by next Thursday.”

SIEGEL: No. Actually it was completely open ended. I didn‟t know what I was doing. I didn‟t know if it was possible and I approached that on a provisional basis with her, telling her that – “Let‟s do this as an experiment.” I had grave questions about whether the important issues such as “affect” could be transmitted, how we were going to deal with that, how I was going to understand the case, and how I was going to understand her as she might possible get into different personal issues that one gets into in a treatment. So we began completely in a provisional basis.

What happened was that we developed a rhythm where she was seeing this 14-year old child twice a week, and the rhythm that we developed was that she would send me her process notes. She had very good process notes, which I think is probably essential in email supervision. She would send them to me maybe Thursday or Friday. I would then have the week-end to work on it, knowing that she was going to be seeing the boy early in the week and that she needed my response because she was interested in learning self psychology; it was a new theory for her, so

53 the delay, I thought, would be difficult. I tried to have my letter back to her sometime by Sunday evening.

The amount of time that it took varied. It takes more time than a face-to-face in-person supervision. There are many reasons for that. It would take maybe sometimes a couple hours. Sometimes if we‟ve got into some very intense situations with the child or with issues that she was struggling with, it might take me 4 or 5 hours to write a letter. That was in the beginning. As time went on it took me much less time.

Now I am working with a group in supervision in Turkey. The reason it is a group was because they were not individually able to manage my fee; Turkey is significantly behind us economically and so I suggested to the person who had contacted me that she consider forming a group of trusted friends, so we are working in a group and my letters now take significantly less time than they did in my first effort.

ALEXANDER: Why is that?

SIEGEL: Because I think I am more familiar with the process. I am more confident. I am able to understand their issues in the written word more quickly now and I have a sense of what they need, so I am able to formulate it more quickly.

One of the very nice things that I have found about E-Supervision, that‟s what I call it, E- Supervision, as opposed to face-to-face supervision -- and we did not do it in real time, we didn‟t do it in a chat room, or real time -- she would write a letter, I would respond with a letter. But the advantage of the letter form is that I had the opportunity to read and re-read her material and think about it for a couple of days before I would respond. I find that to be a much more rewarding supervisory experience for the supervisor in that I am able to think about the material. It isn‟t on the spot. I have more time, so I can think about the material, I can think about the flow of a session and I can begin to craft what I want to say, how I want to say it, kind of define for myself the didactic points that I wish to make. So I found that working in that form was actually a better experience for me and I think a better experience for the people that I am working with than what it would be in real time, back and forth.

Often supervising face-to-face, I find that later on after the session that I might have wished that I said something else, or said something in addition, so I might bring it up next week. But here I have a chance to really think through what is going on and what I want to say. So I find myself composing, thinking about the session on my way when I drive down to work, or composing my response in my mind during the drive, or other times, if I might go out for a run I might think about what my response will be. Actually there‟s an irony here because one thinks of the computer as impersonal and so on but I find it actually to be a more engaging experience.

ALEXANDER: Engaging, how?

SIEGEL: More engaging for me in terms of, I think, drawing me into the process. I spend more time with it than I would with a face-to-face supervision.

ALEXANDER: When you first began, let‟s just stay with the woman, was she writing in English or was she writing in German?

SIEGEL: She would first write in German and then, the poor soul, she would then sit for hours and translate into English what she had written. She thought in German so that was the way it had to go. So it took her a tremendous effort on her part, motivated by her desire to learn the theory.

ALEXANDER: Would you give her things to read?

SIEGEL: Well, she had been -- this is one of the reasons that she wanted supervision. She had been reading the literature in Self-Psychology on her own, but she found that it wasn‟t enough to read it on her own, that she needed someone to talk about it, with as well as the opportunity to apply what she had read to the clinical situation and then have someone discuss that also with her.

I recommended a few things. Generally when I supervise I don‟t recommend things to read. I focus more on the process and I tend to teach as I supervise. There were a few things that I recommended that were a propos to what we were talking about. But as I said my style in supervision is a kind of teacherly style as we go along so I didn‟t recommend a lot to read.

ALEXANDER: How would you define her style as a learner? Sounds like she was a very active…

SIEGEL: Oh, she was a marvelous learner, she was marvelous. First of all she wanted to learn the theory and I think if one is going to attempt to learn in the theory, one really has to immerse oneself in it. She did that, I think, at remarkable sacrifice because she had to think first in German than she had to translate it in English. It took tremendous time; it took her a whole weekend to compose the letter to me. So she was a very motivated learner.

I had another person that I forgot about who was a man also from Germany with whom we attempted supervision, but it really didn‟t go as well. I think that he did not have the capacity to articulate himself in the written word very well so that his notes were quite sparse.

I think that one element of E-Supervision is that it requires of both the supervisee and the supervisor an ability to be very articulate and as precise as possible, which makes up for the missing face. I think that is a big issue – all the nonverbal cues and communications that we receive from each other when we are sitting in a room talking to one other. We had to make up for that deficit. We didn‟t think about that consciously in the beginning; we talked about it later at the end of our experience. But I think that precision and a precise articulation became a hallmark of our work on both of our parts.

ALEXANDER: So she would have to not only write what the experience in the session was, she would have to write what her emotional response was...

SIEGEL: Right, exactly.

ALEXANDER: and then write what her affect was as she would be writing this to you.

SIEGEL: Right, right, although sometimes I could pick up the affect. I mean letter writing is by no means a new form of communication. I think that email has done more for letter writing than I don‟t know what. I think that letter writing for a long time was getting lost as an art form and I think this is very definitely an art form. It‟s very possible to communicate one‟s feelings, but without necessarily saying “I felt this” or “I felt that.” I could tell what she was feeling contextually. But she was unusual in that she had the capacity and the honestly and courage, to tell me what her experience was and remember, we didn‟t meet each other, I was a stranger to her aside from whatever fantasy she had created about who I was. Eventually after about a year of our work we did meet in New York when I was at a meeting and she was similarly at a meeting, but before that, it was all left to both of our fantasies as to who the other one was.

ALEXANDER: Now one of the ironies of this is that in an earlier conversation that we had, Dr. Siegel, you said that the child that she was treated was mute.

SIEGEL: Right, it was an elective mutism. The child was not congenially mute, but he didn‟t talk.

ALEXANDER: So they didn‟t communicate sign language or anything?

SIEGEL: No, no, no. But he didn‟t communicate much in words and that was an issue for us. First of all our language was different, mine was English, hers was German, and we didn‟t hear each other‟s voice so the issue for both of us, she and the patient and she and me was how we are going to communicate with each other, both in this new medium, because the boy was someone who never had any experience of someone who listened to him.

ALEXANDER: So how would she write what – it‟s easier to write down words than it is to write down…

SIEGEL: Right, she would write down descriptions. He wasn‟t absolutely mute – he would sometimes say a word or two, but there were lots and lots of verbal silences. She wrote down what he did, his facial movements, her response, she was very good at that.

ALEXANDER: Was she writing during the session?

SIEGEL: No. No, afterwards.

ALEXANDER: So this is from her memory?

SIEGEL: Right, she could recreate the session. I think in E-Supervision, it is essential that the supervisee have the capacity to do that, or at least that has been my experience.

As I mentioned, I am working with this group now in Turkey. The format there is there‟s one therapist presenting and then I suggested that she write process notes. There are six in the group altogether. I‟ve made an arrangement so that everyone in the group can ask a question per letter. So the therapist writes her process notes and she collects the questions from the five other people plus her question. Often the question is just one question; it goes a question, to a question, to a question. But, then what I do is I answer each of people‟s questions.

Now originally in this supervision, she did not put down all that she was thinking. She was very good about putting down the process between them, but didn‟t put down her own experience. As she became more comfortable with the form of E-Supervision, she began to put down her internal experience, what she is thinking, her dilemmas, what her choices are at any given point, what her responses are, and that has brought a totally different level of illumination to the work. I think that has helped the work move along tremendously.

So just kind of repeating I think, for emphasis, in my experience, my series of three now, I think that it is essential that the supervisee be able to communicate his or her affect as precisely as possible in written word to make up for absence of that presence in the room.

ALEXANDER: Can you talk to us about the parallel process in supervision? First, just to explain it and then to talk about how that comes into play online.

SIEGEL: Very simply put, the parallel process is that idea that the supervisee unconsciously recreates or has similar experiences with the supervisor that the therapist is having with the patient. Actually my series is not great enough; I have only done this with three people and one that I really can‟t count because it never got off the ground with that man. I don‟t know that I am able to talk about, at this point, the nature of the parallel process. I think I have to wait a bit to be able to say something that has any validity to it.

ALEXANDER: Did you find that you experienced that with her at all?

SIEGEL: Well there was a similarity. I guess it does exist too with the supervisee in Turkey now who, just the opposite of the mute boy, she has a young man who talks and talks and talks and in essence says nothing about himself and says quite clearly, “I talk about all these other people in the world because I am terrified of my own feelings,” and so he uses words as a wall to protect himself similarly as in non-communication. So there is that similarity and there is the struggle that I have with this supervisee – and I had with the woman in Germany – about how to make myself understood, for how each of

57 them to make themselves understood, given that our native tongues are different. But I can‟t make a generalization yet to the issue of parallel process. I need more time and experience with that.

ALEXANDER: What about any transference issues that arise between the supervisee and supervisor? How can you tell that is happening?

SIEGEL: It certainly happens. I think that the fact that we don‟t see each other and may never see each other adds to the possibilities for fantasy, which is essential to transference. It makes itself known in terms of how they write, what they write, what they ask of me. In all cases, there tends to be an idealization, again because they‟re looking for access to the theory that I have expertise in, so automatically I am placed on a pedestal in their eyes from the very start. Then the issue becomes how do they deal with that, how does that fit in with their own particular issues? But of course it‟s how does it fit into their own particular issues relative to the treatment, because supervision is not treatment, and the one being treated is always the patient.

I think the issue here depends also on whether the person is in treatment or not. If the person is in treatment then I might suggest that there is a transferential issue here. If it becomes serious enough to call attention to it and something that I think the person might do well to pay attention to in their own treatment, I would do that in a face-to-face supervision. I wouldn‟t take up in a therapeutic way the issues of the transference because supervision is not designed to manage the transference in a therapeutic way; it‟s designed to acknowledge the transference and to help the person know about the transference, but then, the working through of the transference is something that has to happen in treatment. So depending on the need and the urgency, I would suggest that the person consider finding a therapist for himself if they weren‟t in treatment and if it seemed that their work was to either stirring things in them that needed attention or things in them were causing problems in their work.

If everything is going fine then I would just note the transference to myself, not really articulate it except as I might use to illuminate a particular point in the supervision. But as everything, “It depends,” is the answer in this situation as to how one deals with the transference.

ALEXANDER: When you are setting your fee for this, do you bill for “thinking time?”

SIEGEL: No, no, no, no, no, I would never bill for thinking time. First of all, that‟s fun time for me so I wouldn‟t bill for that.

You raised an interesting issue as far as how to bill for E-Supervision because I think it does take more time. To do it properly takes at least twice as long as a session. I am finding now with this group in Turkey that it takes me an hour and half to two hours, but I do it early Sunday morning – I get up, my house is quiet. This is sort of recreational for me. I don‟t mean recreational in that I am playing, but I enjoy it, I find it a lot of fun. It does take more time. I think one has to enjoy doing E-Supervision. One has to like

58 writing letters. I think one has to like the experience. This is what wonderful and exciting for me is the experience, as I said, of being able to think about a session, formulate one‟s ideas after you have heard the whole session and then articulate them in terms of technique and theory in as a precise of a way as one possible can. For me that is kind of a hoot; I like to do that. So I am willing to take the extra time. One is not going to make money doing E-Supervision.

ALEXANDER: You have mentioned also that you are a little bit leery of therapy online.

SIEGEL: Right.

ALEXANDER: Would you like to share some of your thoughts? So many of the people that I have interviewed are so positive about it.

SIEGEL: Well now, of course I haven‟t had the experience, but I don‟t think I‟m ever going to. I shouldn‟t say never, but as soon as I think of treatment online, I get anxious and I pay attention to that anxiety. The responsibility is different and I think the situation is different. I think one has a direct and immediate responsibility for the care and treatment of the patient. One never knows what you are going to get into when one gets into a treatment. Many times I have opened up cans of things that I wished I hadn‟t opened and then once you get in, to switch my metaphor, how do you get the toothpaste back into the tube once you have gotten it out? And if this is all done in written word, there is a significant distance and a lack of immediacy that I would think would be a little bit dangerous. So I am not comfortable doing that.

With E-Supervision, I am not the primary therapist; I still have responsibility and I still get anxious in relation to that responsibility. When I first heard about this boy, the 14 year-old boy, I thought, “Oh, my goodness” because there were many things that made me think he was psychotic. He wasn‟t, but I thought, “Oh my, what have I gotten into?” Also in some things with this group in Turkey there were some things that made me anxious relative to what the supervisee was struggling with and I take the responsibility very seriously.

The difference though between E-Supervision and E-Treatment, for me, is that I am not the therapist; there is someone on site available who can tend to whatever needs to be tended to. The other issue, and this certainly is the case I think with mixed languages, like English-German, English-Turkish, but I think this could be true within the same country is that because the inflections aren‟t there, the opportunity for misunderstanding is enormous, enormous. You know, what we say, the music of what we say -- one can say the same sentence, but with different inflections, it can mean totally different things. Someone is going to read what I write, let‟s say in treatment, and they are going to read it hearing the particular distortions of their own transferences, or let‟s say hearing the echoes or replays of the toxic relationships they might have had earlier in their lives, so they are going to hear what I didn‟t say. Now that happens face-to-face also, but I think it is much easier to deal with that face-to-face.

When you do it email, what I have learned is that sometimes I didn‟t learn about the misunderstandings until way down the road. Again, that could happen face-to-face, but it‟s much less likely because if I said something, and someone misunderstood it and felt injured by what I said, chances are the next session they would come in, they would be kind of flat, kind of down in the mouth. They will sit differently; they might even dress kind of schlumpy. There will be a change in that person which I can see immediately in the waiting room, whereas with email, you don‟t get that. So there is a very important, non-verbal level of communication that‟s not absent totally, but is significantly missing, enough that it causes me caution. So I am not interested. I will let someone else be a pioneer in that area and read what their experiences are before I will take up online treatment.

ALEXANDER: Dr. Siegel, I can see how very thoughtfully and carefully you approach this in a time when it is so easy push the “Send” button. It‟s nice to know that people are really taking the time, that you are taking the time to really be very respectful and thoughtful of what your supervisees are writing you and you‟re really thinking deeply about it and I guess this does give one the opportunity to have that experience.

SIEGEL: Yes. You know I think we owe our supervisees the same respect whether they are in the room or in Istanbul. It doesn‟t matter.

ALEXANDER: Is there anything you would like to add before we close? Have we covered everything?

SIEGEL: I think we have covered most of the issues. I would say, as I have said, that I have found it a lot of fun but I think it‟s also a big responsibility. I think one has to be aware of that. I think so far with every one of these three experiences that I have started, I began with a certain degree of anxiety not knowing how this is going to go and I think I probably will experience that for awhile because I think there are some inherent problems, maybe dangers, and I think one just has to be very very cognizant of that and take that into consideration. One shouldn‟t, as you said, just rush off to the “Send” button.

ALEXANDER: Right. One more thing that occurred to me: would you do online supervision with someone in your own city?

SIEGEL: No, I don‟t think so, even though I have said that I think it is, in some ways, a deeper experience for the supervisor because I get to see the shape of a whole session and think about it for awhile. Well, you know I won‟t say never, but I think in the city, I would prefer to see someone face-to-face.

You raised a question though: “Is E-Supervision something that one only does out of necessity” if kind of from a negative position -- “There is no one there available therefore I have to go online?” Or would one do that as a prescription: “I will do this form of supervision because I think that it is worthwhile?” You know, I don‟t know because I

60 would have to think about that. So right away, I have changed my answer to what I have started with. I would think about it.

ALEXANDER: Well, maybe we will come back to you in a few years and see what else you have learned about it.

SIEGEL: Okay.

ALEXANDER: Thank you so much.

SIEGEL: Okay, thank you for asking me, it was nice to talk with you.

This concludes On Good Authority‟s interview with Dr. Allen Siegel. We hope you have learned from this interview and that you have enjoyed it. Dr. Siegel‟s book, Heinz Kohut and the Psychology of the Self, can be ordered through any major bookseller.

ONLINE THERAPY: CLINICAL and ETHICAL ISSUES

Interview #6: “CLINICAL EXAMPLES”

BARBARA ADAMS, M.S. ED., LPC

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Barbara Adams, M.S.Ed., LPC PMB 341 560 N.E. F Street #A Grants Pass, OR 97526 541-479-7780 Email: [email protected] Website: www.therapyofice.com

Welcome to Interview #6 of On Good Authority‟s program on Online Therapy. I‟m Barbara Alexander.

This interview is with a therapist who works almost exclusively online with clients.

Barbara Adams, M.S.Ed., LPC, is a professional therapist licensed by the State of Oregon. Ms. Adams has been providing counseling services for the past 14 years and has specialized in the treatment of childhood disorders and victims of abuse. She is a charter member of the American Association of Christian Counselors, and provides Christian counseling upon request. Ms Adams is also a member of three honor societies, one of which is in the area of psychology, and she is listed in Who's Who of American Women. Ms. Adams has taught undergraduate and graduate courses in child development, parenting and human sexuality, and has been featured on KJDY, KCMX and KLDR. She has decided to offer online guidance services because of the number of people who find traditional therapy and counseling difficult or inconvenient and would rather express themselves other than by "face to face" therapy.

ALEXANDER: Mrs. Adams, how did you become interested in online therapy?

ADAMS: I had been doing clinical work in a non-profit agency that was primarily for treatment of abused children and their families. After eight years there, I

62 couldn‟t help but notice that some of the clients had an easier time writing about their problems than they did talking about them. This was particularly true with children who had been threatened by their offender, children who might have been told that if they ever told their secrets that something bad would happen, and so these children were extremely afraid of telling what had happened to them. They found it easier either to draw their problem or to write about it. Teenagers especially enjoyed journaling more than talking.

In particular I was working with a teenage girl who really took to writing back and forth. At the same time we had just gotten our first computer in our home. I had discovered chat rooms and I was struck by how many wounded people there were out there without any professional guidance. I thought, “Well, couldn‟t people in the computer world, in cyber space so to speak use some e-therapy?” and so I began to research it. The more I researched, the more I discovered that there weren‟t a lot of people hanging their shingles on the “information superhighway.” So I did some more research and I tried to network with the thirty or so other therapists who were out there already on the internet and I designed my own webpage based on that research.

ALEXANDER: In the course of your research, did you hear pros and cons?

ADAMS: I didn‟t at that time because it was so brand new that no one knew of any “cons.” All I had heard were good things: how that sort of therapy might help people who had issues such as wanting to stay confidential if they lived in a small town and didn‟t want to be seen going to a mental health clinic, or if they had an abusive partner and didn‟t want to leave any signs that they were getting help or going to make a move or anything like that. So all I had heard at that point were good things because it was just so brand new.

ALEXANDER: Let‟s talk about your actual work. What kind of people do you actually--I was going to say-- “See?”

(laughter)

ADAMS: “See,” in quotations. The type of people I work with have a handle on their issues. They may have been in therapy before and they seem to be very aware of what their issues are, what they need to work on, and which direction they need to go. I don‟t find many people logging on for services who have never had therapy before, or who have never decided what to call their problem. Most people seem to know what they‟re dealing with.

ALEXANDER: That‟s interesting because the reading I‟ve been doing on this suggests that most of the people who come to e-therapy, or online therapy, would never have gone to see a regular face-to-face therapist; it‟s their first experience.

ADAMS: That‟s interesting. My experience is just the opposite. Most of the people who have contacted me for services have some cognizance of their problems. Now it‟s true that not all of my clients have had therapy before, but many of them have,

63 and many of them do know what their issues are and what they want to work on, or need to work on.

ALEXANDER: How did you train yourself to do this? Or did you retrain yourself to do this?

ADAMS: Primarily through my clinical work--my clinical experience prior to going online. As I mentioned, working with trauma victims seemed to help a lot in terms of knowing how to deal with people who had a lot of fears or qualms about disclosing things. I find that‟s particularly true on the internet, because people do harbor some qualms about doing business over the internet, especially when it comes to personal problems and personal issues. Sharing personal matters over the internet is “touchy,” especially when you hear stories all the time about hackers, or viruses, or people breaking into someone‟s computer. Confidentiality issues are especially tricky on the internet.

ALEXANDER: What do you tell people about the confidentiality that you can provide?

ADAMS: I make it very clear on my policy statement, which they have to sign and agree with by clicking on it.

ALEXANDER: I read in “Psychotherapy Finances,” that you actually have a button that somebody has to click before they can even register and begin.

ADAMS: Exactly. They have to understand and agree with the abilities and the limitations of online therapy: that I have no control over hackers, viruses, and no control over people who inadvertently, “blow their own confidentiality,” so to speak. They might think that they‟re working with me in private when perhaps they may live with someone who is computer savvy who knows how to track the history of where someone has been and what they have typed in. So I can‟t guarantee 100% confidentiality because of those reasons. Therefore, I have the client sign a form that they understand those limitations and that I can‟t be held responsible. In addition, as a licensed therapist in the state of Oregon, I can‟t be held responsible for any limitation of licensed therapists in their [a patient‟s] state, for instance. So if the laws differ for therapists in their state than they do in Oregon, they sign on my form that they understand that I am operating under the rules and statutes of Oregon only, because it would be just impossible for me, or any other e-therapist to be licensed to provide services in every state, province, and country.

ALEXANDER: That seems like a good way of handling this. It seems to be one of the biggest concerns that therapists have to whom I have spoken: Can you actually work with people from other states when you‟re just licensed in, let‟s say Oregon? Could I do e-therapy with somebody from Florida or Pennsylvania -- I‟m licensed in Illinois?

ADAMS: Yes, there was a lot of controversy about that in the initial years that e- therapy began, and there wasn‟t an immediate answer. The answer seems to be coming out from the professional organizations--the APA, the ACA--that it‟s OK as long as therapists put in some kind of disclaimer making it clear to the client where they are

64 licensed, and that they‟re operating by those state(s) guidelines only. Therapists perhaps might try to find out what the statutes are in the states in which the client resides. That might be sufficient for now until some more global agreement is made among counselors and psychologists about how to handle intrastate policies.

ALEXANDER: What kind of clinical skills do you find most useful for you?

ADAMS: For me I find that brief therapy seems to work the best. In particular, I‟ve found that rational emotive therapy (RET) seems to work very well. I was trained as a cognitive behavioral therapist and that‟s my primary modality. Solution focused therapy also works well online because those models aren‟t as heavily reliant on sensory cues such as seeing the clients or hearing them. We can take a problem in writing and kind of pick it apart and concretely work through it like that, such as using RET by Albert Ellis. We can take an irrational behavior that the client spells out literally via the keyboard, and we can easily challenge those irrational behaviors and pose questions back to the client on email or during live chat. Even the basics of EMDR -- eye movement desensitization -- can be taught via assignments in writing.

ALEXANDER: Really? Could you give us some examples?

ADAMS: Sure. There‟s a client I work with who is an English teacher in a foreign country in a remote chain of islands, and she‟s unable to access care in her area for obvious reasons. She struggles with low self-esteem and she seems to think that she‟s destined to make mistakes with men. She always tends to put herself in situations that are going to sabotage her progress and leave her in a situation where she has completed the cycle of low self-esteem. In other words, she puts herself in situations where she sets herself up to be let down.

So we work on that using RET at times, taking her irrational self statements, such as, “I‟m unworthy of this man,” or “of this situation,” as examples for participation in this activity. We take that and I can write back to her and say, “What are the things that make you think you‟re unworthy of this?” And she can write back and tell me exactly what those things are, and the more we write back and forth, the more concretely it is spelled out that her initial irrational thoughts are kind of ludicrous and not really realistic. Then she has something concrete that she can print out and go over every time she has one of those irrational thoughts that make her feel her low self-esteem. She can re-read our session and question herself using the questions I‟ve already given her, and come to the conclusion that perhaps she‟s thinking irrationally again and she can do something to change it on her own more easily.

ALEXANDER: So you‟ve been working with her actually a rather long time?

ADAMS: For two or three months, yes.

ALEXANDER: Two or three months. Is that a fairly typical length of time?

ADAMS: Yes, it seems to be, at least in my practice. I am aware that there are other online therapists who run specials for, say, unlimited email dialogues for a period of one month or maybe two months and for a certain price, so I don‟t know what their typical length of treatment is. I prefer to keep treatment short just because I believe that if it‟s a very serious and in-depth issue which may not be appropriate to treat online; it might be doing a disservice for the client to encourage them to be dependent on e- therapy. As you‟re probably aware, we‟ve heard of a brand new diagnosis called, “Internet addiction disorder.” Whether or not it‟s truly an addiction or misguided choices I‟m not sure, and I‟m sure there‟s a lot of debate about that. I prefer to keep people off the computer as much as possible, only rely on it when they need it, and to get into life to solve their problems.

ALEXANDER: Now how would you do the rapid eye…

ADAMS: The eye movement desensitization?

ALEXANDER: Yes. How could you do that when you can‟t see the person?

ADAMS: Well, you probably can‟t do a full blown legitimate treatment with it, but I‟ve found that you can write instructions for a client and give them just the basic framework of it, such as guided imagery which is what it‟s based upon and it incorporates. You can teach them how to incorporate an increasingly uncomfortable image into a comfortable state. So those things can be taught just using words, but again if it‟s more in depth it probably needs to be in person.

ALEXANDER: Now I sent an email to all of the people who are on the On Good Authority email list, asking them to submit some questions for the speakers that I‟m interviewing, so I have some questions from some people for you. Dr. Margaret Wool of Providence, Rhode Island, asks a number of very intelligent questions. First of all she says, “What does online therapy mean for people who are not in remote places? For instance, what would it say about people seeking your services who live or work within a half an hour drive of you? What would it communicate about them and the kind of relationships that they would have?”

ADAMS: That is a good question. I‟ve found that it really doesn‟t matter where people are; their reasons for pursuing online therapy seem to be the same. They want privacy. They prefer to just wander over to the computer in their bathrobe or what have you, log on and deal with their issues in their own personal space, in their own personal time, in their own comfort zone. That seems to be the case across the board.

ALEXANDER: She also asks if the very nature of the relationship is going to be different because the people have never met. You have never actually met the people you see online. So would you guess or would you suppose that your relationship would be the same or different if you were actually seeing them face to face?

ADAMS: Oh, the relationship would be very different if it were face to face.

When I first came out of graduate school I noticed that there were certain clients that preferred doing therapy with older therapists, and they weren‟t afraid to tell me either. They would tell me, “Well you‟re not married yet, so you don‟t know what it‟s like having marital problems. We want a marriage counselor who is married and has been through this,” or “You don‟t have children yet and we want someone who has children and has experience.”

Those are all legitimate issues that clients bring up, but trust is a very delicate and important issue in therapy. Without it we can‟t do therapy with our clients, and that‟s the bottom line. Therapy on the internet seems to be a paradox really. There‟s less trust about confidentiality and things like that, and there is less trust about who you‟re really dealing with--if you are who you say you are. They want to verify your credentials and I encourage that by all means.

Then there‟s the flip side to that, where they don‟t want to know who you are; they don‟t want to know what you look like for real, because they concoct their own image of their own ideal therapist in their heads. So I‟m on the other end here doing therapy with them and in some cases, perhaps therapy is more successful because I‟m who they think I am. People can make you who they want you to be--the therapist that they expect you to be -- and there‟s no prejudice really. That‟s one reason I don‟t put my picture on my website. I notice a lot of online therapists have their picture on their website and that‟s probably a good thing. But for me, after doing online therapy for some time I‟ve discovered that I get a lot more online clients who are willing and able to work with me because they don‟t know what I look like. For instance, there are people of other races who might not have sought my help had they known what race I was. Or the age factor: I get to work with clients of all ages now, whereas if I were still in the agency, people might decide they wanted someone older, or wanted someone younger who they thought could better understand them, but over the internet that‟s just not an issue.

ALEXANDER: So there would really be no racial prejudice, no age prejudice and it would work both ways.

ADAMS: That‟s right, and I don‟t ask their race. I do ask their gender for obvious reasons, because that‟s just part of a good assessment. But, I‟m not interested in their race or where they come from.

ALEXANDER: Here‟s another question. Jane Mitchell has asked, “What do you do if you get clients who are vulgar.” I think she means clients who use obscene words, and who are using online therapy as a cheaper version of calling 900 numbers. Does that happen?

ADAMS: I have never gotten that, at least no one who has registered and paid money. I have gotten some emails that left a lot to be desired, but they weren‟t anything I really had to deal with or anything that couldn‟t be dealt with by responding to them in the traditional manor. For example, I would just write back, “Thank you for contacting the therapy office. If you would like to register, please go to the last page.” I‟ve never

67 gotten any problem like that, at least not so far.

ALEXANDER: Let‟s talk about payment because that‟s another big concern. Do insurance companies cover you? How do you bill?

ADAMS: I do not use insurance companies for payment sources, only because when I was in private practice I discovered the piles of paperwork it created. I just personally chose to avoid dealing with insurance companies myself. I have not heard of insurance companies paying for online therapy at this point. I do keep an ear to the ground for that though, just in case. I think that‟s a very interesting concept. But right now I don‟t go through insurance companies. I also find it easier just to do online billing such as virtual checks or going through a payment service like Pay Pal. Those are online services that can guarantee instant payment and it‟s very little effort on the part of the client and on my part.

ALEXANDER: So do you collect ahead of time then, or do you bill after?

ADAMS: I usually bill after. If someone is sending the check in the mail, I don‟t wait until I receive the check, I go ahead and initiate the dialogues and get those started while we‟re waiting for the snail mail.

ALEXANDER: So in that case it‟s no different from face to face.

ADAMS: Right, they can either pay instantly or they can pay later, it‟s up to them.

ALEXANDER: Oh, I see. So how do you charge for your time?

ADAMS: I charge $30 for a one time email response, and that involves the client telling me a detailed background history and specifically what their questions are and what their goals are.

ALEXANDER: Is that something that you have as sort of a semi-requirement--that this is something that they must do first?

ADAMS: Yes, in most cases I will ask for a more detailed background so that I know what I‟m dealing with. It‟s just like doing an initial assessment on someone.

ALEXANDER: Do you use a form?

ADAMS: No, I don‟t. I have a registration form which covers the basics: name, address, and briefly what the person‟s problem is and what he or she would like help dealing with, and how they think I might help them best. Then after I get the registration, I go ahead and write questions based on what the client has provided for me on the registration. So if the client needs help with depression for instance, I write them back and I ask them for additional background history such as: is there any history of

68 depression in the family of origin, can you tell me any of the patterns that you see yourself repeating today that came from your family or origin, what are your current relationships like? Then the client seems to take it from there.

It‟s really interesting what you can tell about the person from what they write back about. If they write back a lot of detail and a lot of background, you can tell kind of what their clinical style might be, what mode might fit them best. For example, if clients would do better with cognitive behavioral therapy or psychodynamic. Some people just write back short, terse answers and don‟t give you a whole lot of background, and that tells you a lot about their level of trust in you or the internet. That‟s something to explore too, namely where that‟s coming from.

ALEXANDER: Dr. Wool had also asked how you can know if the client is giving you accurate information when you don‟t have visual cues. Isn‟t it harder to determine this if you can‟t see them?

ADAMS: To some degree, but then again I‟ve worked with clients in person that I thought were telling me the whole story in person and we‟d done work for weeks and weeks, and I‟d come to find out that they were leading a different life, or just going through the motions to satisfy a court order, or to satisfy their partner. Their intentions were something other than what they disclosed in therapy.

It‟s true that without the visual input you do miss out on something, and especially for me--I‟m such a visual person--this is quite a change for me. I base a lot of my decisions on what I see and not having that on e-therapy--at least at this point in time until I get a video cam set up--it is harder to some degree. Then again, in face-to-face therapy, people are only going to tell you as much as they want you to know. Yes, their facial expressions do tell a lot, but so does their typing. You can tell a lot from what they choose to include in their responses to your questions, and what they choose to omit.

ALEXANDER: Do you use these little things called “emotions?”

ADAMS: Sometimes I do, yes, I don‟t think that there‟s anything wrong with them as long as you have a good clinical relationship with the client. In other words, I wouldn‟t use one of those sideways smiley faces or a wink with someone I was just getting to know. I usually reserve those for after we‟ve have a few dialogues, or later in a chat session. If they‟re telling me something very difficult during the course of a live chat session, I may choose to use one of those to reassure them and to soften the moment, because the computer can be kind of impersonal.

ALEXANDER: So you‟ve really learned a lot about transferring your visual clinical skills to typing.

ADAMS: Yes, I have and there‟s something else I‟ve learned to do that I‟d like to share. You always know that if someone is in crisis, online therapy isn‟t a good idea. Most online therapists will put a statement in the body of their web page stating that they

69 cannot treat crisis clients, and that is so true. It just can‟t be done. There‟s no substitute for one-on-one care when someone is in crisis, or getting the appropriate care through emergency services.

Something I didn‟t realize when I got into this is that there are some other disorders that probably shouldn‟t be treated over the internet, which is another reason I prefer to stick to brief therapy. I was working with a rape victim and the rape had been several years back, but she was in another state two time zones away and we were doing a live chat, which we had done before. One thing that she had never told me and I never thought to ask-- because the rape was in the past and she never mentioned it-- was the fact that she was having flashbacks. Well, lo and behold, we were in the middle of a chat session one day and this woman had a flashback, right in the middle of the chat session. I‟m sure that must have been uncomfortable for her: she was having body memories. It was uncomfortable for me too because I couldn‟t give her my eye contact. I couldn‟t do anything but what I could say over the keyboard to guide her through it, and to give her a sense of safety and reassurance. Then the computer crashed!

ALEXANDER: Oh no!

ADAMS: Yes, and it took me fifteen minutes to get back online, and when I got back online she had left the chat room in crisis and I was very panicked. I always ask for a phone number in my registration form and so I called her at the number she had provided and she was there. So we continued over the telephone for a while and she decided she wanted to go back online and finish, so that‟s what we did.

I would just like to put out the warning to other clinicians: Always make sure when you‟re doing an initial assessment and you‟re treating online that you make sure that the client is not engaging in any symptoms like flashbacks, or any other symptoms that aren‟t quite considered crisis symptoms where you would need to call the police, but other symptoms that could really do some harm if the client was alone. That‟s one experience I will not repeat.

ALEXANDER: Well, you also demonstrated great resourcefulness and flexibility by stepping out of the online therapy and picking up the telephone.

ADAMS: Yes, it was just so imperative that we talk at that point. In fact it might be a good idea if people prior to their live chat session ask for a phone number where the person is in case of something like that happening, or a power outage, or anything like that. Now I do that.

ALEXANDER: That‟s terrific advice.

ADAMS: Thank you.

ALEXANDER: You have really learned a lot..

ADAMS: I have.

ALEXANDER: Getting back to the subject of crisis management, do you try to familiarize yourself with resources and agencies in the person‟s area?

ADAMS: I think anyone engaging in e-therapy is probably well aware of how to navigate the web; after all they found the website that the therapist is on. I think it‟s very important for both clients and therapists to have some kind of mutual resource that they can go to. I think that‟s an excellent idea. I have guided people to certain websites that I think they might find helpful. For instance, I had a man who was addicted to internet porn and I had found a wonderful resource for people with that problem, paradoxically on the internet, but it was a site that he could go to and get more information about that and connect with resources closer to him in his area that he might pursue further.

ALEXANDER: So was your role with him mostly then one of brief evaluation and referral?

ADAMS: I did work with him around that, and we did do some work and it was fairly successful. I haven‟t heard from him in several months, but towards the end of the treatment he claimed to be about 99% cured of that. In other words, he wasn‟t going to those websites anymore. The 1% that I would consider not cured was that he still fantasized about going to those websites, but he was not doing that behavior. Part of what helped was getting his wife involved in the therapy too, and giving her some tips.

ALEXANDER: So would she email you also, or would you email her, or would he pass these things along?

ADAMS: He would pass things along to her. In that case, that is how it worked. Again, you have to just kind of trust that they‟re taking your advice and doing the right thing. You can never guarantee that they‟re totally cured, so to speak.

ALEXANDER: Well, that would be true in face-to-face also.

ADAMS: That‟s true. Ultimately the responsibility is up to the client to follow through on the recommendations.

ALEXANDER: In terms of outcome, do you participate in any outcome research, or have you done any follow-up work or anything like that?

ADAMS: I do like to contact the clients after some time has passed and check in and see how things are going. I don‟t have any formal kind of outcome research set up, but I do like to send a short note telling them that I‟m thinking of them and hoping that things are going well.

ALEXANDER: Do they answer you?

ADAMS: Most do, and they‟ll tell me how things are going.

ALEXANDER: In the example you gave of the woman who had been the rape victim, and your computer crashed, you showed a real level of responsibility for her well-being at that time. It seems to me that in most cases, I wonder about the level of responsibility that people feel for their clients in online therapy as opposed to face-to-face. Do you think it‟s the same or different?

ADAMS: I would like to think that it‟s the same, but unfortunately I get the feeling that it‟s different.

ALEXANDER: With yourself you mean, or with other therapists?

ADAMS: With others, not with myself. I‟ve always been kind of compulsive about following through, and I have trouble sleeping at night if I feel like I‟ve done something wrong by a client, or if I haven‟t done everything to the best of my ability. I‟m just compulsive like that. I wonder about other therapists, because in the other contacts I‟ve had with online therapists--while most are very professional and happy to help, there seem to be many who seem more impersonal or perhaps not as helpful as they might be if I were calling them in person and speaking to them over the telephone.

ALEXANDER: This brings me to something I had said at the start of the interview when we talked about the benefits and pros of online therapy. What are the cons of it, or the downside of it?

ADAMS: Well as we talked about, it doesn‟t work with people in crisis or having suicidal ideation. In fact, it‟s downright unethical, I believe, to be providing virtual services to someone in crisis. I think long term therapy doesn‟t seem well-suited to the internet. The whole notion of the internet is rather fast-paced and relationships on the internet seem to come and go. You don‟t often hear of relationships that initiate on the internet lasting very long. People have their own lives, their real life, and the internet is just kind of come and go, and I think it‟s unethical too to conduct an internet relationship for a long time with someone you‟ve never really met.

ALEXANDER: Anything you‟d like to add before we close?

ADAMS: I think it‟s important for therapists who might be interested in doing online therapy to be aware why the client is choosing e-therapy. It‟s been my experience that most are choosing it for the right reasons. However, I‟ve had a few contacts where I didn‟t find out until later in the consultations that they were having issues with an ongoing therapist that they see in person. Another is example is when I find out that a client‟s therapist is on vacation and you find out that you‟ve been advising the client differently than the primary therapist. Or you have someone with a personality disorder who‟s trying to pit one therapist against the other, or get a second opinion. I‟ve been in some situations like that where clients are trying to get your opinion as to whether or not their therapist is doing a good job, and that can be a sticky situation. So it‟s really

72 important to check into the motives why people are choosing internet therapy before you work with them.

ALEXANDER: Well, thank you very much, Mrs. Adams, for your well thought out approach to this topic, I really appreciate it.

ADAMS: You‟re welcome. Thank you so much, I appreciate it too.

This concludes our interview with Barbara Adams. You may contact her at [email protected]. We hope you learned from it and that you enjoyed it.

At this point, I must say that the views of our speakers are theirs alone and do not necessarily reflect the views of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.

ONLINE THERAPY: CLINICAL and ETHICAL ISSUES

Interview #7: “Clinical Examples”

RICHARD SANSBURY, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Richard Sansbury, Ph.D. 1 Hunters Gate Court Silver Spring, MD 20904 301-572-4950 E-mail: [email protected] Website: www.headworks.com

Welcome to On Good Authority. I‟m Barbara Alexander. You are listening to or reading Interview #7 from On Good Authority‟s program on “Online Therapy.”

In this interview, we continue our discussions with speakers who conduct their psychotherapy practices almost exclusively online.

Richard Sansbury received his Ph.D. in Psychology from the University of Pennsylvania. He was Associate Professor for 8 years at Trinity College in Washington DC, and worked at The Maryland Foundation in Adelphi, Maryland for 4 years. He has been in private practice in Laurel, Maryland since 1984.

As you will hear from his interview, Dr. Sansbury is a lively speaker, and as such has been interviewed many times by the media, including USA Today, The Washington Post, and WGN Radio. In November, 2000, he appeared on National Public Radio‟s program, The Infinite Mind, discussing Online Therapy as an emerging endeavor.

ALEXANDER: Dr. Sansbury, I‟d like to start by asking you how you came to be doing online therapy, or e-therapy, or virtual therapy.

SANSBURY: E-therapy, let‟s call it that. By e-therapy I mean therapeutic interactions that are supported by email. That‟s what I do. How did I come by doing it?

Well let‟s see. I was playing online, it was a hobby surfing the net, and I discovered that some people were doing it and it seemed interesting to me, so that‟s how I got started. From that point, what I did is I made a web page that initially just put up information about psychology, about how to improve your life, and I just put that out there for about six to nine months. Then I opened up a section where people could begin emailing me and I would email them back.

ALEXANDER: Just little questions, sort of like Ann Landers or Dear Abby?

SANSBURY: Yes, very much like that. From there it grew, people wanted to do more extensive work, so now I really focus on opening an exchange with someone that‟s going to go on for some time.

ALEXANDER: What percentage of your practice would you say is e-therapy?

SANSBURY: It‟s been growing, I would say now between 60 and 70% of my practice. Ultimately I plan to be almost entirely online. The reason for that is I really enjoy doing that kind of work. One of the perks is that I can do it at my convenience and wear my chicken suit while I‟m responding.

ALEXANDER: What else do you enjoy about it?

SANSBURY: When I get an email I read it at my leisure, and I re-read it as many times as I want to, I get to think about how I want to respond, what I think will be the most effective response. So I can take my time and create a response that I am pleased with, and then send it to the client.

ALEXANDER: Do you ever feel pressured?

SANSBURY: Yes, I‟ve had that experience, but that‟s the exception not the rule.

ALEXANDER: So people who write you understand that it may take a day for you to really reflect and consider your answer?

SANSBURY: Yes they do understand that and I attempt to be very clear about that right at my website. One of the things that I think is very important for online work is to have the client have informed consent. I try to be very explicit about what they can expect when they‟re working with me online. For one thing, they will hear back from me sometime within 24- to 48-working daytime hours, excluding holidays and weekends. What that implies is that doing work with me is not an emergency service. If they need emergency services they really shouldn‟t be looking for those online. They need face-to- face help, or to go to an emergency room. What can they expect beyond that? That‟s part of why I have my website up. There are many pages there and I recommend to people that they read through the website, because they will get a feeling for the way I think about psychology, the mind, and how to fix things when they‟re not working to your satisfaction.

ALEXANDER: Do you diagnose or assess online?

SANSBURY: You are asking some very good questions. That is a hot issue. As you know, therapists do have this trinity. Not a holy trinity but close: assessment, diagnosis, and then treatment. I believe, and others might well disagree with me about this, but you cannot do those things very well online, at least not in e-therapy -- therapy supported by e-mail. The reason I say that is when you think about assessment, someone comes in your office. If they‟re wearing a chicken suit you are probably going to notice that and that‟s going to come up for conversation. Online I can‟t tell that. There are lots of obvious visual cues and auditory cues that you get face-to-face that you will not get online.

It‟s for reasons like that that I say you cannot do a thorough assessment online, and I am slightly worried about the people who are pretending they can. So if you can‟t do a thorough assessment, you‟re not in a position to do a diagnosis so I don‟t even attempt to give people diagnoses online. Anyone who is going to say right up front, “Look, we don‟t assess, and we know we don‟t asses, and we‟re not going to attempt to give you a diagnosis” -- I think they‟re on the right track because with e-therapy, you can‟t do either of those.

Now that‟s not to say you don‟t do some kind of assessment because I do. I have to get some idea in my mind about what is going on for this person before I begin responding to them, but it‟s just not the full assessment that you need to give a diagnosis.

ALEXANDER: Would you be able to do some rough assessment? Let‟s say you were in a chat room or using instant messaging with each other where it is more a conversational, real- time mode.

SANSBURY: Would that help? Is that what you‟re asking?

ALEXANDER: Yes.

SANSBURY: It would help some, but still I am not going to have any of the visual cues. That person in the chat room could be crying so much they can barely see his or her screen. I‟m likely not going to know that unless they tell me. I‟m not going to see their face flush, I won‟t see them gritting their teeth, I won‟t even hear them laughing-- not in chat. Chat is just very fast email.

ALEXANDER: What kind of work can be done, and what kind of problems can be treated?

SANSBURY: Well, again it‟s not treatment. Treatment is the third part of that trinity we were talking about: assessment, diagnosis, treatment. At least when I talk about treatment, I mean a process in which the therapist is pretty much in charge, and doing something TO the client or patient. The therapist can fine tune what he or she is doing in

76 that interaction. You know, on a real-time basis, a therapist gets feedback from that client as to how he or she is responding to the process. And because the therapist can fine tune it, that‟s closer to what we consider “treatment.” When you‟re online, you‟re helping someone, but I‟m a little reluctant to call that “treatment.”

What kind of issues can I help people with? Many of the same issues that I would help people with if they came to my office. It‟s just a different way of approaching those problems. I find online that a lot of the cognitive behavioral interventions work very nicely for life problems.

Another general kind of thing that people complain about is something we might call “symptoms,” that is, “feeling” symptoms such as feeling anxious, depressed, unhappy. Those kind of immediate symptoms I find respond fairly well to Neuro-Linguistic Programming (NLP) interventions. So I can help people get some pretty quick relief using NLP techniques online. I just teach them about something called, “sub modalities,” because not everyone has heard of NLP. NLP is a set of communication skills and techniques for communicating effectively to the unconscious mind -- to and with the unconscious mind. These techniques are helpful in dealing with those feelings and emotions that trouble people, because many of those emotions are generated out of unconscious thoughts and attitudes.

ALEXANDER: Can you give us an example of a situation where you would us that method?

SANSBURY: Sure, someone writes me and says, “I‟m depressed. I feel really bummed out and I don‟t want to feel this way.” So I write them back asking them, “Okay, what are you thinking, what are the thoughts that are going along with this feeling?” And very often they‟ll say, “Well, gee I don‟t know; I don‟t think I‟m thinking anything. (People don‟t really pay a lot of attention to these thoughts.) So I would write them back and say, “I understand that it‟s not going to be obvious to you at first, but please begin paying attention to the thing that you are saying to yourself. Try to remember the little pictures that flip into your mind quickly and are gone again almost as quickly.”

When people start looking for those kinds of things, they then find them because they are there. It‟s very much as if I ask you, “How is your left ear feeling right now?” Well before I asked you, you probably didn‟t know, but once I asked you to start looking for it you can then tell me: “Well it feels numb,” or “It feels a little warm,” or “It itches a little bit.” Once I direct their attention to these kinds of things they can give me that information. Now it‟s invariably that they are picturing things that are going to make anybody feel bad. They are saying things to themselves that would make anyone feel bad.

ALEXANDER: You wouldn‟t be asking them what happened that made you depressed? You‟d stay away from that, you would not be exploring circumstances or histories; you wouldn‟t be looking for that particularly?

SANSBURY: Not at first. At first I would say “Let‟s do something that would help you with your immediate symptom, you‟re feeling bad.” Ok, then once we had done that, and they were experiencing some relief, then we would get into the larger scale issues: “How did you get there? What is it about the things you believe and the way you‟re conducting your life that got you to that place.” But this is my own style, and I wouldn‟t go into their childhood immediately, for example, and start dealing with childhood issues. That‟s not to say that someone else couldn‟t do that, it‟s just that I don‟t do it.

Once you are aware of what you‟re doing, then we mess it up basically: “If don‟t like the results, if you‟re unhappy or depressed because of the way you‟re thinking, then we‟re going to go in and change the way you‟re thinking. And one of the ways you change it is by simply observing it.” It‟s amazing how effective that can be: simply paying attention to what you‟re doing and then playing with that. For example, “I feel depressed because there‟s this voice in my head and over and over again it‟s saying, „What‟s the use, what is the use?‟ It doesn‟t matter what I do.” Well one very simple thing I can do is change that voice so that it sounds like say, Mickey Mouse, or Goofy, and if I practice that a few times that voice is not going to have the same impact. What I just told you about is a very simple sub-modality intervention.

ALEXANDER: That‟s terrific.

SANSBURY: And it works.

ALEXANDER: I can see that it would, I can see that that would be perfectly applicable for online therapy, and they‟re short answers. Have you found this to be extremely time consuming?

SANSBURY: (laughter) Yes, it can be. When I started, my fee structure was based on unlimited use; that was my favorite thing. That would be three or four emails a week that I was exchanging with a client, and those emails could be very long and that could take a lot of time, and it did take a lot of time. Obviously I couldn‟t make a living that way so I had to change some things and I now get paid by the minute. The more time I spend responding to an email, the more money it will cost the client.

ALEXANDER: Do you actually have stop-watch by you?

SANSBURY: No, I don‟t have a stop-watch. I just look at a clock.

ALEXANDER: So you do a rough…

SANSBURY: Yes, I sell people chunks of email time and they buy that before hand, and then they use up their clock. Now if they stop interacting with me and they still have time in their time bank, I‟ll reimburse them, I‟ll credit their account.

ALEXANDER: Do you take credit cards online? Is that how it works for you?

SANSBURY: Yes, that is how it works for me, but there are different options. I have a form on my site. One of the problems I personally have is that my site is not on a secure server, so I recommend to my clients that they do not send in their credit card information over the form at my site. Although the option is there, I explain to them that it‟s not secure. I also have what‟s called a “hush mail.” Hush mail is a web-based secure email service, and anybody can set up a secure email service there for free, so I recommend as an option that anyone who wants to work with me set up an account and then send in their credit card information over that secure account.

Another option is that they can call my answering machine and leave the information there, and that‟s secure. So security is always an issue online, and for those people who want their emails to be secure, we can exchange email via the hush mail account. For three years in fact, I offered something called PGP, Pretty Good Privacy, which is an encrypted email software package that you can get for free at MIT. You can download it from the MIT site, but it‟s too cumbersome for people to use. They don‟t want to go through the trouble of doing that so they don‟t. We‟ll see about hush mail, I don‟t know.

ALEXANDER: That example you gave about neuro-linguistic programming was so super. Could you give us any other examples?

SANSBURY: Another example would involve pictures. You can do things just like that only with visual images. People often are not as aware of the visual images they have in their head. Some people are, for example, listening to the language that you‟ve used. If I were working with you and you were saying, “I‟m feeling pretty anxious,” then I would ask you what kind of pictures you have in your head? You know, “When you approach that elevator and think about getting on that elevator, what is it that is happening in your head?” And you might say, “Well, I have this picture of me falling down the elevator shaft, and I‟ve become uncomfortable right after I look at that picture,” and I say, “Well that‟s not surprising. How do you want to change that picture?” or “Let‟s explore changing that picture and see what that does to how you feel.” So we‟re back to doing sub modality interventions.

You might go, “If you move that picture off to the right rather than having it straight in front of you, does it feel the same?” And chances are very good you would say, “Well no it doesn‟t,” or we could change the color, or we could change how far away it is from you. Notice we haven‟t really changed the content. It‟s still the picture of you falling down the shaft. If we change its color, or if we change how far it is away from you, or if we change where you see it, all of those things might change how you feel when you look at it.

ALEXANDER: Ok, here‟s a different kind of question, what if somebody writes you with a relationship problem? For instance, a mother might write in and say, “My teenage daughter is driving me crazy.” So then how would you deal with that? Would you say, “Oh, tell me everything that‟s going on,” or would you deal with the relationship issue or the “driving me crazy” part?

SANSBURY: I would start with what is presented to me and I would ask, “Would you tell me specifically, give me a specific example of an exchange and how that drives you crazy, and what you mean by being driven crazy?” So I would get very specific and ask them, “What different thing do you want to have happen?” Then we‟d go about the intervention at that point, once I knew specifically what they wanted. Now I would not launch into, “Give me the history of your relationship and how you might have gotten there” and that kind of thing.

ALEXANDER: So one good thing for people who want to do online therapy is to be able to start at the very top, at the very straightforward presenting issue. For someone who‟s been working, let‟s say psychoanalytically for a long, long time, the first impulse is to go to why, what, describe the history of this. It‟s different, a retraining, a relearning isn‟t it?

SANSBURY: I am not saying that. Really what I‟m doing is describing for you the way I work. I am not saying that a psychoanalytic approach will not work online; I suspect it will work online. It‟s going to take longer, however. It‟s not a brief intervention model. That doesn‟t mean it‟s not valuable for people, because I think it would be, just like in face-to-face. So I don‟t think it‟s necessary that you would retrain yourself, because you may just port all the skills right into the online arena.

The one thing I would say about being online: people want instant gratification and instant information, instant results. You might have to struggle with that a little bit with your clients online.

ALEXANDER: True, very true, that‟s a very excellent point you made. Do you call the people who contact you “patients,” or do you call them “clients,” or something else?

SANSBURY: You‟ve been to my site, haven‟t you?

ALEXANDER: Well, I read your interviews in Psychotherapy Finances.

SANSBURY: I call them “users.” I have struggled with this. I don‟t want to call them “clients” because I want to distinguish between face-to-face interaction and online interaction. You know, when you sign up with an ISP you‟re a user of their services, and that‟s the way I mean users.

ALEXANDER: Is there a different liability? Would there be a different level of responsibility or liability if you were calling them patients or clients, do you think?

SANSBURY: I don‟t know, somehow I doubt it. I don‟t think that a lawyer or a judge is not going to care what I call them. They‟re going to define them according to the way they want to define them. The reason I‟m using that word is that I want my client to have it very clear in his or her mind that the online environment is different from the face-to- face environment. There are different rules, it‟s a different kind of relationship, and that‟s

80 what I‟m trying to stress and keep in the front of their mind.

ALEXANDER: Speaking of the relationship, do you deal with transference issues, with idealizations, with the various projections that the user might place on you?

SANSBURY: All the time.

ALEXANDER: Oh really?

SANSBURY: Online is a great place for projection, because if you think about it you only have written words there, and the tone… you‟re going to project, you‟re going to build up this image of who is talking to you and what they mean. And people who are into projecting to begin with are going to really do it online. So yeah, I deal with that all the time.

ALEXANDER: So for instance, would somebody come right out and say, “You think I‟m stupid?”

SANSBURY: They sure do, or “I‟m really angry at you for criticizing me.” I respond, “What? When did I criticize you, what did I write that was critical of you?”

ALEXANDER: Do you find that happens more readily, that people are more ready to be out front with that because it‟s not face-to-face?

SANSBURY: Yes. Many people are much more prepared to be upfront with a lot of stuff online. You name it; they‟re more upfront with it online, because they‟re not face- to-face. That‟s one of the big pluses for online work, that people feel a little bit more secure because they‟re not actually in front of another human being. I‟ve had many of my users be very blunt about it, saying: “I would never go to face-to-face therapy dealing with these issues. I just feel too -- I feel ashamed,” or “I would feel that if I want to talk about this I‟m going to be judged.” But somehow online they will.

ALEXANDER: Perhaps many of our listeners right now who have been in email correspondence with people will note that when they are writing, they are more emotional. It‟s somehow a much more emotional modality in a sense, more even than letter writing because it‟s so fast.

SANSBURY: That does make a difference doesn‟t it? That the turnaround time is faster than writing a letter, and that does make a difference.

ALEXANDER: And just the actual putting thoughts onto substance, onto a substance.

SANSBURY: Like journal writing, yes.

ALEXANDER: It‟s faster than journal writing.

SANSBURY: It is faster.

ALEXANDER: Unless you keep a journal online, you know in Word Perfect, or in Microsoft Word or something. That‟s a very intimate form of writing.

SANSBURY: Yes and when you think about the process, you‟re writing or actually you‟re hitting a keyboard, and then you see it up there, so you write it and then you read it, so it‟s being fed back to you. In some sense you experience yourself right there, even before it gets sent, and that can amplify a feeling that you might be having.

ALEXANDER: Do you have any sense of what can‟t be done in online therapy?

SANSBURY: Emergencies. You don‟t deal with emergencies online.

ALEXANDER: And yet crisis hotlines do, the Samaritans do, don‟t they?

SANSBURY: Well, they‟re not really doing emergency interventions, because it‟s an email reply, and that email can take time to come back to you, it can take days. You know if someone is suicidal they don‟t have days to wait, they need a response right now, so they should get on the phone and call a hotline. Online is not good for emergency services--at least not yet. There will come a time when we have the bandwidth to support audio-visual exchange over the internet, but we don‟t have it yet. I mean some people do, but that‟s one in a thousand. The everyday person online doesn‟t yet have the bandwidth to really make it seem like the therapist is inside that computer. You know, they can talk to them in real time. And once we have that (technology) it will be pretty much the same as face-to-face work online. We‟re not there yet, but we‟re doing something different. By the way, I suspect that email and chat will remain an important therapeutic tool, even when we do have that broadband stuff.

ALEXANDER: Because people are still not going to want to be seen.

SANSBURY: Right, that‟s right. The written word offers possibilities that are taken away face-to-face.

Ok, let me say something else. I mentioned emergency services and that online is not good for emergency services. In addition, in my experience, people who have trust issues, if they tend to be paranoid, or paranoid-like, they‟re too worried about too many things: what you‟re trying to do to them, or what you really mean, or why you‟re being so mean to them. It can get really out of hand. Online is not a good place for them. People who have strong trust issues in my experience are not going to do really well online, but that might be my own limitation. I can‟t really say that someone else might not do wonderfully with this. I would just put it out there: if you‟re going to work online, you may want to pay some attention to this.

ALEXANDER: What about standards of care? Do you know about any standards of care developing for e-therapy?

SANSBURY: That is a very hot issue because there are people online who are attempting to transport psychotherapy with all its standards of care, and apply them directly to the online environment. And these people tend to say things like: “You should not be treating someone.” They will use the word “treat” online, unless they are within your district where you‟ve been licensed to practice with people face-to-face in the traditional sense.

Let‟s say I‟m licensed in the state of Maryland. If someone from Pennsylvania writes me, do I have to say to them, “Nope, I‟m sorry; I can‟t work with you because I‟m not licensed in Pennsylvania?” Some states by the way have laws exactly to that effect. California jumps to mind. Florida I think is another state. According to the rules in California--it‟s not a law--the board that manages that in California has issued a decree that citizens of the state of California can only be treated online by therapists who are licensed in the state of California. Now how are they going to stop somebody from France giving services to someone in California, I do not know, but the rule is there.

ALEXANDER: Well, if it were at the level as I said Ann Landers… Ann Landers doesn‟t have to be licensed and she‟s not doing treatment. If somebody writes and says, “I need some advice on whether I should ground my sixteen year old daughter,” that wouldn‟t be treatment, per se.

SANSBURY: I would agree with you. What I say and others, some people at least would agree with me: that people don‟t get treatment by email, it‟s something else. It‟s advice; it‟s an educational service, not a treatment service. That‟s what many people would say, but that does not stop some regulatory agency in California saying, “No we define treatment this way, you are treating them and we‟re going to take you to court.”

ALEXANDER: Well, I wonder if the scope of practice defined in your licensing act defines psychology, let‟s say as, “assessment, diagnosis, treatment,” so you‟re defined as somebody who does “treatment,” then anything you would do online would be treatment, even if it were only advice.

SANSBURY: What is happening now is we are making obvious, at least to me, that online is an uncertain place to be. So if someone listening to this conversation is thinking about going online, think about your tolerance for uncertainty. If you have a very low tolerance for uncertainty, stay away from the internet because it is an uncertain place. It‟s the cutting edge. We now are beginning to create what the rules will be; we don‟t know what they are yet.

ALEXANDER: Do you have any idea about a good rule that we should all pay attention to?

SANSBURY: I sure do. I think what we need to do is have informed consent. Give consumers the right to accept services from whomever they want. But I think as a provider, it is my responsibility to make very clear on my website that when they come

83 through to reach me, they know what to expect from me, and what they can‟t. If you want to go and look at my website, anyone listening to this, you will see that I bend over backwards to do exactly that and I think I owe it to the consumer so they know what they‟re getting.

ALEXANDER: This is an ethical issue and it‟s a character structure issue. You have to be a person who has good boundaries, and many therapists don‟t.

SANSBURY: Good point, excellent point, yes.

ALEXANDER: But I would say that particularly for this work, there can‟t be any sloppy boundaries.

SANSBURY: You know I don‟t think we‟re ever really going to eliminate sloppiness in boundaries, but that is our target. We want to be very clear. But not just boundaries -- that makes it sound a bit negative you know, and I don‟t think of it as negative. I think of it as “Here is something I can offer you; this is what I can give you. If you like this, then let‟s go for it. If you don‟t, then you need to go somewhere else.” I want them to know what this package is, so it‟s not only the limitations, but that‟s part of it.

ALEXANDER: And of course you have to stick to your own guidelines.

SANSBURY: Yes, otherwise they‟re not real, and that can be difficult. I have had -- it‟s just amazing -- I mean I say in a number of places on my site that this is not for emergencies, that online work is only for mild psychological conditions. Then I have multiple personalities emailing me in crisis. I mean this is not mild!

ALEXANDER: What do you do? What do you say?

SANSBURY: Well, I say, “You need and you deserve better treatment and more help than you can expect to get online. Please contact a face-to-face therapist.” Then I will go and give suggestions on how they might do that depending on where they live. And then I have in the past, offered supportive, a few supportive emails: “How are you doing, is everything going ok, have you called?” But then after that I don‟t get into their basic issues, but I don‟t just say, “Get out of my face.” I give them a little support as long as they‟re pursuing the face-to-face help.

ALEXANDER: One more question, at least, one more question. Is this financially viable?

SANSBURY: It‟s getting there, at first there would be no question that NO would be the answer.

ALEXANDER: Because of the time…

SANSBURY: Because of the time. That‟s changing. It is becoming financially viable.

ALEXANDER: Due to your developing skills?

SANSBURY: Yes in part, plus I charge more. Basically I now ask for a dollar per minute of my time. Now, that‟s still not as much as face-to-face, however, it‟s really convenient, and sometimes I can save myself some time. For example, If I‟m writing something about sub modality interventions, I have a library that I‟m creating for myself where I explain sub modalities . That chunk is in the library so when I get a new email client that I need to explain this to, I don‟t have to write it again. I plug that in. So over time, it‟s taking me less and less time to provide more and more service.

ALEXANDER: Is there anything else that you would like to add before we close?

SANSBURY: If you‟re thinking about going online, you need to have some skills with a computer. You need to know something about computers, you need to know something about the software that you are going to use to do the things you want to do online, and you need to know something about the internet. How much do you need to know? I think you need to know enough so that you become comfortable with your ignorance, because you‟re going to have a lot of ignorance. There‟s going to be a lot that you don‟t know, but you need to know enough so that you can get online and operate the software that you‟re going to need to operate to be online, such as Windows. Are you‟re going to use a Microsoft product for emailing? Are you going to use Netscape for its instant messenger program? Or maybe you‟re going to use something else like AOL. You need to be able to use those things to do your email work.

And how are you going to do email; how are people going to find you? Are you going to write your own webpage or are you going to hire someone to write a webpage so people can find your webpage. Or are you going to join an organization that already has a webpage setup, and has services available for therapists who want to be online. There are such organizations, and you go and pay them a fee, and you use their websites.

ALEXANDER: It‟s like opening an office.

SANSBURY: It is. It‟s exactly like opening an office only you‟re doing it virtually. And then, what are you going to do online? You‟re going to be writing, so do you have writing skills? You‟re going to need them online, and you‟re going to need to write clearly. When I first was thinking about that, I was thinking that you need to be able to write logically, but not necessarily, because it‟s possible to use metaphor online. So maybe you‟re just going to write a story.

My closing thought about this, right now anyway, is I think it is a lot of fun. I really enjoy the process. I think that because I have time to think about what I‟m going to say to people, I can do a much better job and I really enjoy that. We are reaching out to a

85 brand new population. These are people who would never go to a therapist office, but they will contact people online. That‟s exciting.

ALEXANDER: That‟s a very important thing.

SANSBURY: Yes that‟s right, and you‟re worldwide. I have worked with people from all over the world. People in Japan, Canada, South America, Europe, it‟s worldwide. I think that‟s kind of fun.

ALEXANDER: Well, I really want to thank you very, very much for the detail, the detail of your examples, and the carefulness of your thinking. I really appreciate that.

SANSBURY: Well, thank you, Barbara. I hope it‟s useful for people.

This concludes our interview with Dr. Richard Sansbury. We hope you learned from this interview and that you enjoyed it. Listeners wishing to contact Dr. Sansbury may email him at [email protected]

I must say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.