Online Therapy: A Book Review
Larry D. Rosen, Ph.D.
The National Psychologist
I just finished reading “Online Therapy: A Therapist’s Guide to Expanding Your Practice” by Kathleene Derriz-Palumbo and Foojan Zeine (Norton 2005). The book is geared primarily toward helping therapists develop their own online practice. Given the nearly 100% saturation rate of computers among potential clients, this trend makes sense. And according to the authors it is a rapidly expanding field increasing from only 12 online therapists in 1995 to 300 in 2001 and 5,000 in 2005!
The authors spend a considerable amount of time laying the groundwork and rationale for online therapy. Using candid interviews with Albert Ellis, Don Meichenbaum, Harville Hendrix and others, they present a case that online therapy can be effective with approaches that range from cognitive-behavioral to transpersonal. In addition they provide a strong case for its applicability (and success) in treating problems including PTSD, body image, drug addiction, anxiety, phobias, suicidal ideation, and a host of more medically related issues like insomnia, weight and general health concerns.
Who is appropriate for online therapy? According to Derriz-Palumbo and Zeine, nearly everyone may be appropriate although it is particularly attractive to rural people with difficult access to psychotherapy, inmates, people suffering from shame and guilt making it difficult to seek psychotherapy, shy people, and high tech young people who feel more comfortable talking to a computer. However, modalities may differ depending on the client. At this time, e-mail therapy is the most popular format. Online support groups are also a source of service, as well as web or computer-based treatments, computer-assisted health education, psychological assessments and virtual reality treatments. In addition, chat rooms and instant messages are rapidly becoming useful vehicles. Video-conferencing therapy is on the horizon. The authors do point out that there are differences between using synchronous communication tools such as instant message as opposed to asynchronous messaging where one communication receives a response at a later time. Obviously e-mail is asynchronous. Issues concerning both types of communication are discussed in this book.
In Chapter 4 the authors provide a case for how and why e-therapy is effective. They point to studies by the International Society of Mental Health Online (ISMHO) for the past 5 years. Spearheaded by Michael Fenichel and others, ISMHO has provided manuscripts concerning both a clinical case study group (www.fenichel.com/csg6.shtml) and myths and realities of online clinical work (http://www.fenichel.com/myths/). Both are essential readings for future e-therapists.
Fenichel and the book’s authors discuss a variety of reasons why e-therapy can be effective. With the cloak of anonymity provided by the computer, patients feel disinhibited and therefore more self-disclosing and honest. This has been proven by countless studies of computer-mediated communication. In addition, writing itself may be therapeutic as it stimulates self-reflection, as seen by therapists who encourage patients to keep diaries. Other authors on e-therapy have pointed out that health information (documents, web sites) can be delivered in a much more timely fashion through e-mail. Finally, e-mail messages provide a written record of the interchanges which allow both the client and therapist to re-read and continue to process the information. John Suler (http://www.rider.edu/~suler/psycyber/suler.html), another pioneer in this area, calls this the “zone of reflection.” With all these advantages clinicians currently using e-therapy suggest that coupling online sessions with face-to-face sessions may be optimal.
The bulk of the book is devoted to the nuts and bolts of establishing an e-therapy practice. Chapter 3 presents guidelines for doing e-therapy, including advice for the first session, early and middle sessions, and termination. The authors provide a list of issues to avoid and how to work with specific client groups. They even discuss issues like boundaries and transference and their role in e-therapy. Chapters 5 and 6 along with several appendices present concrete issues like an e-therapy business model, how to develop an e-practice and technical issues concerning web site development, necessary technology and online resources. Of these, only Chapter 5 and Chapter 6 seem warranted given their unique advice. The other chapters and appendices appear to be far too elementary for even the most novice therapist. Anyone who desires an online practice would find little need for how to buy a computer or how to find online resources.
Information about ethical regulations appears in Appendix C. This is certainly important information and although referenced several places in the book, it seems like this information deserves more than an Appendix.
Overall, I feel that this book is an excellent primer and resource for someone considering establishing an e-therapy practice. Although some of the material is quite elementary, most is right on target. The addition of interviews in the first chapter is quite compelling. Reading what Albert Ellis has to say about doing REBT online or Don Meichenbaum talk about psycho-educational uses lays the foundation for acceptance of online therapy by the psychological community at large. If I were starting an e-practice or even considering one, I would definitely read this book as well as publications on Suler and Fenichel’s websites and material online at ISMHO.
I’d like to offer one additional note on virtual reality. In my opinion, the ultimate use of technology in psychotherapy is the ability to have the computer simulate environments that scare people. Afraid of flying? Try a virtual reality airline flight. Sit in a chair and don a helmet and you actually feel like you are in an airplane. If you are scared at take-off the computer can be programmed to give you countless virtual take-offs. If you are scared of spiders, elevators, or thunderstorms there are virtual reality machines ready to help you through your fear. Although virtual reality therapy is relatively new, research is starting to show its benefits. It’s not cheap, but it is effective. I saw a video demonstration where a woman, who was so afraid of heights and could not even walk up a flight of stairs, was taken through eight virtual sessions and shown standing on top of her roof.
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