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David Baxter

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On-line therapy: the faceless cure?
April 22, 2006
by Sharon Crawford, Toronto Globe and Mail

At first, Toronto therapist Kali Munro was a little leery about meeting her clients in a chat room. What about privacy? If the client used the name "Blackdog" or "Sweetiepie," who else would log in, lurk or, worse, leak the confidential information?

Click forward a few years. Kali Munro, now president-elect for the International Society for Mental Health Online, considers e-therapy a good alternative to face-to-face help. And she isn't alone: More and more people are logging on to find help for problems they can't or won't take elsewhere. They meet one on one with a therapist in a chat room or exchange e-mail with a counsellor.

Thanks to Internet accessibility, on-line therapy is manna from cyberspace for our 24/7 lifestyles, especially for anyone who can't face a therapist.

"It's more difficult for men to go into the office and actually be seen," says Guelph, Ont., counsellor Lawrence Murphy, who with Vancouver-based counsellor Dan Mitchell pioneered on-line therapy.

Both counselled at B.C. Addictions Services in Surrey, B.C., in the mid-1990s. In 1995, they combined computers and counselling and founded Therapy Online, originally as a bulletin board service (Today, it's internationally respected.) Now, they teach other therapists cyber-counselling through the University of Toronto faculty of social work.

"There's a greater sense of control," Mr. Murphy says. "The client is alone at the computer and no one's staring at him and judging."

Or it could be "someone in a small town having an affair and the only therapist is their brother-in-law." Or a disabled person or someone whose second language is English who can take time to reply. Their clients, adults to the age of 45, reside in Canada, Australia, New Zealand and Britain.

Most of Ms. Munro's clients are women in their 20s to 50s in Canada, Britain, the United States and India. She counsels on several issues including sexuality, relationships and abuse.

She says some clients have difficulty sharing their emotions in person because they carry shame about their sexuality. Detailing it on-line helps.

Chat and e-mail eliminate body language, in-your-face emotions and voice tone. On their website, Mr. Murphy and Mr. Mitchell suggest ways to make typing on a keyboard feel more like a therapy session. When e-mailing, they place a chair beside them and suggest clients do the same. That chair represents the other person and makes that person more real than screen text.

Mr. Murphy uses the chair for on-line role play. If the client argues both sweet and sour sides -- anger at a spouse but also wishing to forgive -- "you invite the other person to sit in the chair," says Mr. Murphy, who e-mails the process to the client. The client sits in the chair and types in the anger, then stands, walks, returns to the chair and types in the forgiveness.

Clients and therapists visualize each other in the chair while typing feelings in brackets, such as this generic script at therapyonline.com.

"Client writing to therapist: I have reread your last TherapEmail several times and although I appreciate your words [can't believe you have such faith in me] I don't think I'm ever going to have a worthwhile relationship [very very sad]. Richard called again to say I'm an idiot [angry with myself]. He's so mean. But, hmm, now that I think about what you said again, I think I'm actually more angry with him than with myself. [Weird. I feel pretty good just now]."

"One of the most important part of the counselling process is [for clients] to acknowledge to themselves they're not a failure," Mr. Murphy says. He includes snippets from previous sessions' progress in current e-mail messages and tells clients, "I want you to read this list and reflect."

Chat therapy is instant. Ms. Munro continually asks, "How are you feeling?" notes client pauses and ascertains if the writing becomes cryptic or if the person is a slow typist. She types, "Seems like you're having a hard time."

She uses sentences, but switches to short form when she knows her clients better. "They take the lead." If the pace escalates, she types "right" and "I see," for nodding and smiling.

Not every therapist works on-line. Some are skeptical about treating people without seeing them. "I find the personal contact is very important." Toronto psychologist Linda Gruson says. "There are a lot of emotional issues and it's important to pick up a person's emotions for relationships. [With e-mail], there are so many things you can't do -- meditation, hypnosis, relaxation."

On-line has its own difficulties -- Ms. Munro has been booted out of her chat room. The first time, she worried that her client might think she had deserted her. But she rebooted and returned. Now, she has a backup e-mail address and phone number.

Bigger concerns (privacy and ethics) exist. Therapy Online uses PrivacEmail.com, a neutral domain name integrated into their website, where clients pre-register. It leaves no computer traces and contains built-in security for emergency therapist action.

Ms. Munro's chat room is embedded in her website, password protected, with host service. In the U.S., "the practitioner has to be licensed in the state where the client is," Mr. Murphy says.

On-line therapy isn't for everyone -- client or therapist -- but results can be positive.

"I've seen people being effective, confident, knowing who they are, improve communication with partners and friends," Ms. Munro says. "It's quite something to 'see' people grow."

Getting e-help
  • Research different therapists on-line. Make sure they have specific training doing on-line therapy
  • Send an e-mail message to see if they are experienced with your problem or similar problems.
  • Make sure therapists belong to a professional organization requiring them to adhere to ethical guidelines.
  • Find out the cost. (Usually an hourly rate similar to conventional therapy.)
  • Make sure that the service (chat or e-mail) has a secure encrypted system.
  • Don't use public computers. Use your own computer, which other family members cannot access.
  • Try out the chat or e-mail to see if you and the therapist get along.
  • If the connection between you and the therapist doesn't feel right, switch therapy or therapist.
  • On e-mail, make sure the therapist will respond fairly quickly.
  • With e-mail, read over your message a couple of times before pressing "send."
 

Lana

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As I read the article, I kept thinking, "Yes, there is the question of whether you have the right client (as opposed to impostor), but there is also a question whether you, as a client, are chatting with the said therapist"

In addition, it is way too easy to assign incorrect tone, or wrong association of what is being said giving an entirely different context, facial expressions, body language all speak volumes that offer insight. I may be speaking with bias here, but as someone that had to rely on the unspoken (tone, body language, facial expression) to guage action and survive, I just don't see how such session can get anywhere. I think in some cases, missing such vital yet subtle signs, can be right down dangerous.

I think this very forum is way better then that type of "therapy".
 

Peanut

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I may be speaking with bias here, but as someone that had to rely on the unspoken (tone, body language, facial expression) to guage action and survive, I just don't see how such session can get anywhere. I think in some cases, missing such vital yet subtle signs, can be right down dangerous.

This is slightly off topic but related to what you said Lana. I just wanted to say that I learned something similar in my class yesterday. I learned that if someone is communicating two conflicting messages, one that is verbal and one that is non-verbal, that people will usually believe the non-verbal message.

Anyway, I just kind of thought that agreed with what you were saying. It would be hard if you could not see the funny looks your therapist was giving you all the time :eek:
 

Halo

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Hi All,

I have read the above post by Dr. B. and I have to say that from a client's perspective I would sometimes like to do on-line therapy as I find while in my face to face sessions I tend to pre-think what I am going to say and how I am going to say it because I don't want to sound stupid and get a bad facial expression from my doctor. I think that I would be more comfortable with on-line therapy for that reason.

On the other hand, if I look at this from a therapists point of view...I think that face to face contact is needed so that they can get a "read" on the patient. Sometimes what comes out of my mouth does not coincide with my facial/body expressions and by being face to face she normally can pick up on the body language and call me on it.

So basically I can see both sides to this issue but I have to lean towards face to face therapy as being the best (for me anyway).

Nancy
 
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I wonder also if this type of therapy would be better than no therapy at all? I live in an area where at this time there aren't any counseling resources available. I've looked at various online counseling sites and some of them seem kind of iffy, but some of them look reputable.

It's discouraging when you really don't have any options to go see someone in person. Also there are people who can't get out for whatever reasons, physical ailments, agoraphobia or something like that, maybe a lack of transportation. It's a real struggle for many, many people just getting somewhere to see someone.

Maybe it would be an ok option for some people. Maybe not for most people, but what if there aren't any other options?
 

David Baxter

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Janet said:
I wonder also if this type of therapy would be better than no therapy at all?

I definitely think so. In spite of my worries about on-line therapy, that was a big factor for me in making the decision to start this forum. How much help you can get in places like this is, I think, limited but it is better than no help at all.
 

ThatLady

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Online therapy sites and forums are definitely not a substitute for face-to-face therapy, in my opinion. However, Janet's point is also valid. There are those who just can't see a therapist for one reason or another. For those people, sites like this one...and others that are reputably run...are a darn sight better than nothing.
 

jkb

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I can see both sides yet as Janet mentioned for those of us that are agora, live in secluded areas etc, online therapy and forums can be just as effective. Also with forums not only are you able to get support you also are able to interact in all ways with others..form friendships etc. This for example in my case allows me to have that "connection" which in turn doesn't make me feel alone/isolated as I would if they did not exist.
 

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