This work is a chapter for the Academic Press book "Psychology and the Internet", edited by Jayne Gackenbach. Copyright and all rights therein are retained by Academic Press. This material may not be copied or reposted without explicit permission. (Copyright 1998 by Academic Press).
Cite as;
King, S. A & Moreggi, D. (1998). Internet therapy and self help groups - the pros and cons. In J. Gackenbach (Ed.), Psychology and the Internet: Intrapersonal, Interpersonal and Transpersonal Implications (pp. 77-109). San Diego, CA: Academic Press.
Internet therapy and self help groups - the pros and cons.
1V. Support groups online.
Support groups are distinct from self-help mutual aid groups in that they are organized and led by a trained mental health professional. Such facilitated group therapy online is very rare at this time, however, it is potentially one of the most important aspect of online therapy, in terms of the therapeutic value to clients. In small, closed online support groups the advantages of text based relationships clearly start to outweigh the known disadvantages. Online support groups, of the type proposed here, do not yet exist. Before discussing the few trial efforts that have been made with similar formats, a hypothetical case study is provided in order to clarify exactly how these groups can operate, and to define their potential value.
Traditional f2f group therapy is the model for online support groups. The example here will use a group that is focused on recovery from shyness. Any pathology that is not extreme or involving a thought disorder could be addressed in this manner. There is as yet no empirical data that demonstrates the efficacy of an online support group, but research in this area is progressing. There are no claims made that online treatment of this kind is a suitable substitute for f2f group therapy. As an adjunct to traditional therapy, or as a method of last resort for someone who is unable to present for f2f treatment, these groups could ethically be organized and run by a licensed professional.
1V A. Hypothetical model.
Dr. Lineon has been a practicing, licensed psychologist for years. His specialty is shyness, in all forms, everything from Generalized Social Phobia and Avoidant Personality Disorder to mild social inhibitions. He has been accessing online self-help groups for these conditions for some time. He has participated in professional cyberspace forums and knows first hand how easily flame wars start. He decides to recruit subjects for an online support group. Dr. Lineon posts a message to alt.support.shyness and several open email lists that are self help groups for shy people. His messages state that he is forming an online support group and interested parties can access his web site for screening. On his web site, he has a list of questions for potential clients, as well a full disclaimer about this form of therapy. The questions ask the potential clients about their current involvement's in f2f therapy, the severity of their disorder, and if they have ever thought of harming themselves. A disclaimer informs the potential clients about the limits of confidentiality in this medium, and the lack of empirical data supporting this form of treatment as being beneficial. Information about the logistics of the proposed group are provided, so clients will know the time commitment they will be asked to agree to, if included in the group.
The first 6 clients meeting the inclusion criteria are sent email confirming their participation. They are asked to print out, sign and send back a consent for treatment form by snail mail to Dr. Lineon. This form asks for the clients real name, address and phone number as well as the name and number of the clients primary care physician, and an emergency contact number.
The group is to run 12 weeks. Once a week the group meets in real time on a secure chat room forum in a MUD. All clients are subscribed to a closed email list moderated by Dr. Lineon. At the commencement of the group, initial messages are solicited that introduce group members to each other, and deal with finding a common time to meet in real time in a text-based virtual reality. As members come to know details of each other, a variety of very personal self-disclosing notes appear on the group list. Feedback is given by group members as well as by Dr. Lineon. The weekly 2 hour real time meetings in the chat room provide an opportunity to socialize and increase the feeling of being connected.
Dr. Lineon refers members to web pages that provided psychoeducational material that addressed recovery from shyness. He also monitors members postings very closely to see if any misunderstandings arise. When needed, Dr. Lineon sends privet email to individual members to help them avoid such misunderstandings. Members share with each other the addresses of web sites and other resources they find useful. Towards the end of the 12 week period, closure for group members is effected along similar lines as f2f treatment. Members are asked to summarize the gains they feel they have made, and comment on the insights they see others have achieved.
1V. B. Discussion of hypothetical case.
One of the known advantages of text based relationships is the ease and convenience of access. By providing therapy on an email discussion list, clients have the ability to schedule their participation at their optimal time. One factor that limits interpersonal closeness on the large, open self help online groups is the lack of boundaries. Such open forms are loosely organized and members come and go without notice to others involved. This case example of an online support group shows how this disadvantage is overcome. The boundaries are set, in terms of the number of members, and the time commitment to participate. The moderation of the group prevents the kind of argumentative flame wars that can disrupt open online self help groups. Dr. Lineon uses the ability to approve of every message posted to the group, and asks potential argumentative members to reconsider before posting to the list. This is an ability that is not possible in f2f groups. There is no preventing group members from sending each other private email. Members must be encouraged to bring such "backchannel" relationships to the group process. There is no equivalent to this capacity in f2f groups. It would be similar to two group members whispering to each other, which could only occur if they were sitting near each other. In the online group, any member can send a private message to any other member, with content that relates to the group process. A example of this would be a private email exchange that said something like "I think Joe was holding back in his last note. What do you think?"
It is also possible for the facilitator to have private conversations with individual members. This is not done in traditional f2f therapy, and the advantages of this are unknown at this time. This ability is defined in a public posting from a researcher (Childress) who is currently implementing online therapeutic interventions. "As a replacement for the loss of nonverbal cues, a procedure may be implemented of providing a private email back channel between group members and the group facilitator. Private email communications between the facilitator and the individual group members would allow group members to privately express personal concerns to the facilitator. The facilitator could then help the member raise and resolve these concerns within the group setting. Such a private, email backchannel may actually be superior to the reliance on reading nonverbal cues in f2f groups and may be an advantage of cyberspace groups over f2f groups." (Childress, 1998).
Some of the known ethical, legal and moral obligations the therapist has to his clients in this hypothetical case study are accommodated by the extensive screening done and the fully informed consent solicited prior to treatment starting. Other ethical, legal and moral imperatives remain undefined. It is not clear at this time just how a licensed mental health worker can provide online services to people from other states and other countries, when their license to practice is often restricted to one state or country. The fact that this is occurring, and has advantages to some, is spurring regulatory bodies to accommodate new communication technology
1V. C. Support for this model.
Herman, a psychologist working at the University of Southern Mississippi, developed and tested a protocol very similar to the above described group therapy. His HOPES (High-tech Online PsychoEducation and Support) model included online recruitment, a professionally led closed discussion group and web based educational material. He ran a group for people having trouble making career decisions for 4 weeks. "The data suggest that the presence of an active group moderator can improve outcomes on certain variables and lead to greater satisfaction with treatment. This study has demonstrated the feasibility of conducting an entire psychoeducational intervention, and an evaluation of that intervention, on the World Wide Web." (Herman, 1997)
A group online intervention similar to the HOPES model was done with a population that included people with AIDS/HIV and women with breast cancer. The Comprehensive Health Enhancement Support Program (CHESS) connected clients by closed email discussion groups and provided access to online psycho-educational material. Participants were able to send email questions to doctors and other expert professional authorities on their condition. Outcome data suggest that using CHESS helped to improve quality of life and decreased usage of health care resources among participants (Gustafson, Hawkins, Boberg, Bricker, Pingree, & Chan, 1994)
Colón is a social worker with experience leading online support group therapy efforts. In an article describing her impressions of this work she sates "Geographical constraints can be overcome without compromising group interactions and processes. Online groups may make supportive therapy more attractive to clients who would not otherwise pursue therapy; online groups also offer privacy, informality, and equality for some clients. The group may also serve to diminish social isolation, anxiety and depression. As a result of these achievements, closely held assumptions about the way psychotherapy can be done are being altered." (Colón, 1996)
In 1997, Dr. Bob Zenhausern and Michael Benjamin organized and ran an online support group pilot study that matches the model given above. They recruited clients from an email list called SimGroup (simulated group therapy online). The therapist, Michael Benjamin, lives in Israel. Six members communicated daily on the closed email list, and met once a week in real time in a text based virtual reality chat room environment. Reports from the group participants showed they had a high level of concern for each other and an experience of a transformitive relationship with the group. (See http://rdz.stjohns.edu/~Group/) An explanation of how this group was structured, and a description of some of the logistic problems that were encountered, is provided here by one of the participants. "The group consisted of three men and three women in addition to the therapist. The first week was taken up with logistics -- what times people were available, what programs people were using or might need (telnet, etc.) -- as well as short introductions. During this time we also discussed issues of confidentiality and the protocol for the group. It was decided that each week one person would present an issue to the other group members. Each member would provide two separate responses to each issue: one would be about their own personal feelings and experiences related to the presenting material and the other would be feedback to the presenter. Then the person who presented the issue would write about his/her reaction to what had been sent by the group members. After that, the group therapist would write an overview of what he thought or would ask questions of various individuals to expand upon or clarify what they had expressed. Each segment was done by email to the whole group and took one week. Issues arose about whether email communications which were spontaneous and related to personal situations would be permitted or whether that would result in chaos. The group decided (democratically) that, although staying with the protocol provided a necessary structure that prevented multiple crazy-quilt conversations all going on simultaneously, it was just as important not to stifle the on-going concerns of group members that might not fit neatly into our planned format." (Personal communication from Lea Hooker <lhooker@sirius.com>, 20 Feb. 1998)
Group therapy is a valid method of treatment for many psychopathologies. The development and research of online support groups will add another modality to this from of intervention. Training courses are being developed that will assist professionals in gaining the knowledge needed to effectively lead online support groups. Video connections may allow future therapists to work with video mail and video conferences as a means of implementing support groups for geographical remote members.