The Online Clinical Case Study Group
of the International Society for Mental Health Online

A Report from the Millennium Group

I. Origin and Purpose of the Group

Case presentations cover the wide range of styles and formats for online clinical work.

The worlds of psychotherapy and the Internet have come together. Clinicians are encountering an increasing number of clients whose lives have been affected significantly by their activities in cyberspace. In a wide variety of styles and formats, psychotherapy also is moving onto the Internet. What are the special skills and knowledge that clinicians need in order to adapt to this intersection of cyberspace with the mental health profession?

In the months before the turn of the millennium, the International Society for Mental Health Online (ISMHO) created its Clinical Case Study Group. Organized and facilitated by John Suler and Michael Fenichel, the group is devoted to the discussion of psychotherapy cases and professional clinical encounters that involve the Internet. The creation of the group evolved out of the need for more in-depth explorations of clinical cases in which online life and interventions play an important role. There are many online groups devoted to discussions of counseling and psychotherapy in cyberspace. Usually those discussions are speculative, theoretical, and anecdotal - which often leads to a dialogue that lacks centeredness and a real world anchor. The goal of the case study group is to generate a more systematic investigation where real clinical cases provide a practical, experience-near grounding for the discussion.

The group's philosophy is that clinical work involving cyberspace sometimes will resemble traditional in-person psychotherapy, but also that cyberspace has resulted in some very new clinical issues and intervention formats. Therefore, the group is designed to investigate cases that cover a range of topics:

• face-to-face (f2f) therapy cases in which contact with the client via the Internet played a significant role (e.g., e-mail between sessions, the use of web sites as resources)
  
• short and long term clinical encounters with people that occurred primarily via the Internet (e.g., therapy via e-mail or chat)
  
• professional consultations that occurred via the Internet, including, for example, giving advice and/or information to people who contact an online professional
  
• supervision via the Internet (e.g., via e-mail or message boards)
  
• f2f therapy cases in which the client's activities in cyberspace were a significant issue in the therapy
  
• online groups and communities in which the mental health professional acts as a organizer, facilitator, or consultant

II. The Group's Format

The group's design is intended to maximize cohesion, participation, and group identity.

To help maximize confidentiality, cohesion, and group identity, the list is kept small in size and is closed during case presentations. The "Millennium Group" which began in the Fall of 1999 consisted of 16 mental health professionals from diverse backgrounds. All members took turns describing their cases as a stimulus for group discussion. Beginning on a Monday, each presentation and the ensuing discussion typically lasted one week (a pace that at times made it difficult for some members to keep up). A separate "format and process" thread was used to discuss technical problems, observations about the process of the group, and suggestions for improving it. At the beginning of the group, a message from the facilitator outlined some guidelines:

• Give feedback to each presenter. None of us wants to take the risk involved in presenting our work and then having no one respond. Chronic lurking is not OK on this list.
  
• Avoid long, scrolling messages. Be concise. It will be harder on you to construct a precise, to-the-point message, but the net result for everyone will be a more focused, less overwhelming batch of messages.
  
• Avoid long quotes of previous messages. Quote the specific sections you are responding to.
  
• Let us know when you will be away from your computer for extended periods of time.
  
• Be HELPFUL to the presenter, not critical. We will expect respectful, professional behavior on this list. Persistent disrespectful behavior will result in your being unsubscribed. Appeals can be made to the ISMHO Executive Committee if you disagree with the decision to remove you.

A problem with many e-mail groups is their amorphous membership and process. Often the implicit norm is that you can subscribe and unsubscribe whenever you want, participate or lurk as you wish, respond to others, ignore them or digress. This lack of structure sometimes leads to a group that is fragmented, disorganized, and lacking in group spirit and identity. The guidelines of the IMSHO case study group that are listed above - as well as the rule that every member must present a case - are designed to counteract these tendencies. They help create focused discussions, personal commitment to the group, and a supportive, cohesive atmosphere.


III. The Group's Ethical Guidelines

The confidentiality and welfare of the clients discussed is the group's prime directive

After the initial introductory stage when members sent a message describing themselves and their backgrounds, the Millennium Group discussed in depth the ethical dimensions of the group's format. The welfare of any clients or groups that would be presented in the cases was considered of paramount importance. As a starting point, the group discussed the ethical standards of the American Psychology Association regarding the use of confidential information for didactic purposes:

      (a) Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their patients, individual or organizational clients, students, research participants, or other recipients of their services that one obtained during the course of their work, unless the person or organization has consented in writing or unless there is other ethical or legal authorization for doing so.

      (b) Ordinarily, in such scientific and professional presentations, psychologists disguise confidential information concerning such persons or organizations so that they are not individually identifiable to others and so that discussions do not cause harm to subjects who might identify themselves.

At the end of its discussion of ethics, the group created a document that outlined it's own guidelines. These items above were included in that document. The group also included a list of questions that encourages its members to consider the unique ethical aspects of a cyberspace case study group. The issues embedded in some of these questions reflect the group's philosophy that clinical work involving the Internet has opened new territory not previously encountered in traditional f2f therapy - especially issues regarding online identities and access to computer records (#1 and #4). Question #1 is considered the "prime directive" with #2 being an extension of it.

1. Are you protecting the confidentiality of the person or group by disguising and/or deleting information that could directly or indirectly reveal the person's online or offline identity, or the group's identity and location?
2. Does anyone on this list have direct or indirect contact with the person/s you will discuss, and could this jeopardize the person's confidentiality or in anyway harm those person/s?
3. Has the person given permission for their case to be discussed?
4. What precautions have you taken to safeguard the security of messages from our discussion group presentations (i.e., how have you restricted access to your computer and these email messages)?
5. Are you requesting explicit permission from the appropriate individual and/or the whole group to use quotes or specific material for research, teaching, presentations, or publication?
6. During your discussions with people OUTSIDE of this list (professional or otherwise), how will you protect the confidentiality of the list and the cases presented here?

IV. The Types of Cases Presented

Reflecting both the diversity of our group's professional backgrounds and the wide variety of presenting problems which members were asked to address, group members were privy to a wide variety of clinical presentations. Ranging from issues of online relationships, to more global functioning within family, work, and community, there were numerous opportunities to explore the efficacy of online treatment approaches and the extent to which both practitioners and clients benefited from new and unique approaches towards integrating online and offline experience.

In keeping with the group's established guidelines for confidentiality, the names of clients were changed, often to poetic or symbolic representations of the case dynamics, in keeping with a long tradition of clinical case presentations, dating perhaps to the writings of Freud (e.g., " The Case of Little Hans", or the "Wolf Man"). The designated case title (e.g., "The Case of Miro", involving an artist) would then become the subject header for the particular case being discussed by the group participants, and constituted the primary discussion thread for that week.

An overview of the Millennium Group's case presentations, distilled from over 900 posts between November 1999 (following a month of developing guidelines) and the end of the first group cycle in mid-April 2000, would highlight the following cases:

--Case #1 An online support group oriented towards career counseling and support
This case involved a focus on how both counselor and participants communicate support and advice. Both practical issues (e.g., resume writing) and self-esteem issues were explored. Additional discussion concerned aspects of how the group and therapist reacted to specific career choices which were not universally viewed as "socially acceptable".

--Case #2 Individual online treatment (e-mail and chat) for severe anxiety and depression
This presentation centered around the development of online treatment parameters and goals. Also raised by the group were issues of emergency contingency management and observations about the intensity of the process despite absence of f2f meetings. This case utilized an actual transcript of a session, which offered the opportunity for a closer examination of both process and content, and stimulated a lively discussion of ethical, practical, and technical concerns.

--Case #3 Adjunctive daily online sessions supplementing f2f therapy
Here was an approach which proved effective in a complex case with a fragile patient. Issues of boundaries were highlighted, along several dimensions relating to both anxiety and addiction. A need for structure, backup plans, and coordination between service providers, was a major focus.

--Case #4 Online group dynamics and the issue of "lurking"
This presentation consisted of an exploration of how individual member non-participation ("lurking") can effect the vitality and cohesiveness of online groups. A look at group norms and guidelines became a subtext for discussion, including an exploration on how "back-channel" communication may have impacted on the process.

--Case #5 Online life (and inner life) becoming the focus of f2f treatment
In this presentation, a case was presented where despite the treatment occurring exclusively face to face, it was clearly the discussion of the client's online autobiography and creative work that became a turning point in the therapy. In this case presentation, the concept of "twinning" was introduced, as well as the oft-repeated themes of empathy and of online dis-inhibition.

--Case #6 Issues arising from an online support forum
This presentation focused on two separate cases, one highlighting the phenomenon of "chat room addiction" and the difficulties inherent in referring to offline treatment, and the other centering around one group member's exhibitionism and flamboyance. The intersections were explored in terms of individual and group dynamics, dependency, false identity, and "lurking".

--Case #7 E-mail, intimacy, and f2f treatment
The focus was on intimacy, in this case of a client involved in online romantic affairs, seeing a therapist f2f but also using e-mail between sessions. What emerged among the group was an exploration of the ways in which this facilitated expression of intense and immediate feelings.

--Case #8 Multi-dimensional treatment for social phobia and anti-social online behavior
A number of complex issues were addressed here, including substance abuse and destructive use of the Internet. A variety of approaches were discussed and utilized, including a focus on social skill training, and a combination of supportive f2f treatment, online assignments, and education.

--Case #9 Dynamics and limit-setting on a message-board community
Focusing on a thread of discussion which took place on an online message board, this presentation addressed the social dynamics within one online community and explored the issue of the group leader's role in defining and enforcing limits.

--Case #10 Psychotherapy in a chat room
This presentation detailed the stages of ongoing work with a depressed client refusing outside treatment, from the initial intake, to the process of becoming engaged in online treatment. A transcript reveals an almost "live" quality to the interactions, which focused on spirituality.

--Case #11 TDD for MPD
Here was a fascinating case where a precursor to e-mail, TDD, was used in the treatment of someone whose multiple personalities expressed themselves via both voice and text - which were the basis for this treatment. Challenging enough f2f, online work presented special challenges.

--Case #12 Brief marital therapy
This presentation described a situation where a couple was affected by a spouse's online romances. While this case, like Case #5, did not directly employ the Internet in the treatment itself, online life was clearly a major component in the offline treatment content.

--Case #13 Online love and offline therapy
Here a woman with chronically low self-esteem, whose marriage had become empty, found --through the anonymity of Cyberspace-- someone who accepted her and grew to love her. After years of treatment f2f, she now maintains e-mail correspondence with her therapist.

--Case #14 A closed message board community
In this case, a closed community provided a safe place for an otherwise socially inhibited abuse victim to use anonymity and support as a means of utilizing "homework assignments" and modeling to develop social competencies and improved sense of self.

--Case #15 Online treatment for social phobia
Online treatment for social anxiety proved very effective in this case, employing elements of several treatment modalities, including use of cognitive exercises and use of a journal. During the course of treatment this client, once unable to converse with men, became engaged.

--Case #16 Online support and counseling
Here is the case of a woman seeking support from several sources online but resistant to engaging in what appeared to be much-needed local f2f treatment for self and family. The discussion highlighted a number of issues about the limitations of pro-bono "treatment" online.


V. Clinical Issues

Online clinical work draws on traditional concepts and techniques, but it also requires new ones.

Historically, clinicians have been inclined towards positing several "universal" features of effective therapeutic interventions, including warmth, genuineness and empathy, progress towards specific goal attainment, and use of appropriate interventions. Certainly the experiences which have been presented here and explored in detail are no exception, and if anything tend to affirm the importance of such "traditional" concepts and principles. However, as opposed to f2f therapies, a plethora of new factors are introduced by virtue of the processes involved in communicating electronically from one individual to another--or to a group of individuals simultaneously-- relying on the Internet, computer monitors, and written language skills rather than on one's eyes and ears and oral language. While clear advantages and opportunities arise, such as the ability to "time shift" through the use of asynchronous communication or to "location shift" by use of synchronous chat, obvious difficulties can also come into play beginning with such basic issues as knowing the identity of who one is speaking with, and their age, emotional state, and gender, for starts. These issues, as important as they are, have by necessity been mentioned only briefly here, to allow for a discussion of the many clinical (as well as technological) issues associated with the online cases which are the focus of this paper.

As noted earlier, it has been posited that online treatment approaches tend to mirror traditional f2f therapies in many key regards. Aside from the more "universal" aspects which most therapists can agree are essential in any therapeutic endeavor, it is also clear that clinicians come into the treatment arena with varying frameworks and backgrounds, which often become reflected in how one conceptualizes the process of the treatment. Thus, some of this group, whose training (and even nationality) is quite diverse, have focused on aspects of the therapeutic relationship using differing conceptual prisms. Some were inclined to look at the cognitive underpinnings of narrative reports, others were focused on aspects of providing a "holding environment" or facilitating a safe haven for self-expression, while still others demonstrated intuitive and/or pragmatic approaches drawing on any number of theoretical orientations. One of the advantages of the collective knowledge and experience base assembled together in this group was the opportunity to be exposed to, or re-acquainted with, a number of theoretical frameworks, ranging from cognitive-behavioral, through object-relations (e.g., Winnicott), through group-process (e.g., Bion, Yalom), through traditional psychoanalytic and interpersonal theories and back full circle to emerging theories of online behavior and relationships.

The specific cases described above included both the type of presenting problems which are typically seen in traditional office practice, and some uniquely fin-de-siecle issues which could hardly have been envisioned by the forefathers of psychotherapy.

Some of the most compelling and persistent issues which arose across many of the online cases presented by the case study group included:

• Disadvantages of absent f2f cues - Ranging from facial expression to confirming someone's real-time focus on the communication, knowledge of appearance, emotional state, sobriety, and even true identity, these were all important data which were not explicitly available. Often this was seen as a distinct disadvantage from the provider's point of view, and in at least one case presented by the group, a client used anonymity to act out inappropriately towards others in ways which might not have been seen otherwise. In this case discussion ensued about both the potential and dangers inherent in doing social skill training using chat rooms.

• Advantages of absent f2f cues - Sometimes the ability to maintain anonymity empowers clients to "be themselves", facilitating their commitment to engage in treatment. The issue of shame relating to appearance or verbal presentation was in fact a recurring theme. Several clients related poor self-concept and shame-based interpersonal difficulties in their daily lives, and described a sense of exaltation in feeling free to be spontaneous online, and being appreciated for their "real" self , both in treatment and in meeting people socially online.

• Understanding the intricacies of online behavior and relationships - Clinicians sought to utilize cues such as writing style, content, and time delay, to understand the depth of communication with both the counselor/therapist and with reported online and offline "significant others". In online group environments, additional factors emerged, such as the tendency of some group members towards "lurking", taking only a passive/voyeuristic stance rather than an active role in contributing to the group process, or in some instances engaging in passive aggression or behaviors which monopolized the energies of the group. On the other side of the screen, there were reportedly instances of jealousy, anger, and alienation which arose among family members in reaction to clients' time spent connected to others online.

• The diversity of issues regarding the Internet and psychotherapy - From concrete goals such as career decision-making, to a "problem-solving" approach towards generalized interpersonal anxiety, to emotional support during periods of disequilibrium or crisis, it was clear that our 16 clinicians were presented with a wide variety of presenting problems from among a diverse population in which the single common denominator was involvement with the internet. As diverse as the cases were, some members of the case study group felt there were yet more issues to explore.

As difficult as it to generalize about "psychotherapy" in a therapist's office, clearly it is infinitely more problematic to make conclusive statements about the process or outcome of general classes of online treatment. However, for those of us who engaged in thoughtful exploration of these cases, it was clear that many positive outcomes were and are being achieved, including in some cases client-reported symptom reduction, improved range of social functioning (online and off), motivated participation in both f2f and electronic treatment approaches (sometimes in the course of the same integrated treatment), and in some cases with less dramatic outcomes (so far), more subtle benefits may have been gained, such as self-confidence, self-knowledge, practical advice with regard to career or online behavior, or the receipt of a strong recommendation to pursue local treatment where in fact that was felt to be important. And most importantly, perhaps, those of us who participated in this combination of peer-supervision and clinical case conference group, learned more about what we need to continue exploring. We only know the tip of the iceberg, and the emergence of an Internet society will surely bring about ever-increasing demands to develop a society of mental health services in response.

Through activities such as this - and with the support of professional interdisciplinary organizations such as ISMHO - clinicians will continue to move beyond purely theoretical speculations into understanding and developing the strategies which prove most effective in online counseling and psychotherapy. The cases presented here suggest not only that the roles and intervention strategies of online clinicians will draw from traditional theories and techniques, but also that they will evolve into new and innovative forms that are very different than the familiar f2f approaches. In the future, the case study group will continue to explore this new territory with the aim of developing a practical conceptual model to guide our understanding of how and for whom the various forms of online interventions can be applied most effectively.

* The members of The Millennium Group included Azy Barak, Peter Chechele, Tom Crain, Michael Fenichel, Betsy Frier Walker, Robert Hsiung, Jim Jarvis, Gayla Novitsky, Pamela Rudat, Gary Stofle, John Suler, and Willadene Walker-Schmucker.

For more information contact John Suler or Michael Fenichel

Members of ISMHO are welcome to join the case study group.

CURRENT TOPICS in PSYCHOLOGY      ISMHO       PSYCHOLOGY of CYBERSPACE

---

Copyright © 2000 John Suler & Michael Fenichel. All Rights Reserved.