Psychotherapy in Cyberspace

The destructive aspects of certain Web-viewing habits have been increasingly documented in recent months and years. It is now, perhaps, appropriate to discuss one of the positive and therapeutic advantages of the Internet.

A significant part of my private practice is conducted at a distance via e-mail. Some correspondents are former clients who have moved out of the area; others have sought me out because they seek an understanding psychotherapist who will not be shocked by their paraphilias—erotic sado-masochism, cross-dressing, fetishes, etc. (an area in which I was working long before these became a popular fad); and some live close enough to my office but are too embarrassed to talk face-to-face. They reach me mostly through word of mouth. It is a modality that can be both highly efficacious and cost-effective. I know of only two practitioners (both in New York State) who use this modality; perhaps the description below will encourage other therapists to explore it.

Initially, I ask for a detailed case history

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including family structure and attitudes, dating, eroticism, relationships, fantasies, fears, health, and past psychotherapy. I also ask for a prepayment of $200—by money order—to cover my initial 120 minutes. These two requirements help me weed out those who are not sincere (especially those who see me as a recipient for the e-mail equivalent of deep-breathing). The money order also allows the client to remain anonymous (the secrecy problem will probably arise spontaneously by the third “session”).

I charge the client only for the actual time I spend in reading the incoming e-mail and writing my response—20 to 30 minutes for the average session. The patient does not pay me for the time he spends in ruminations, thoughts, or searches for the right word, and I can afford not to charge him for the reflections about his latest message that will occur to me while I’m driving or reading the paper or having my dinner (out-of-session insights often draw from a deeper, more intuitive, well than thoughts that are acutely focused in time and place).

The process, for obvious reasons, tends to lean heavily on cognitive-behavioral “instructions.” The patient may, for example, write “I feel such a fool, so incompetent. Everybody else that I know is happy. I don’t think I shall ever get what I deserve.” To this, I may respond with suggestions:

• to draw up lists, e.g., “list all the ways in which you are and are not a fool”
• to discover the absurdities resident in the assumptions about one’s world, e.g., “Every morning, before you shave, look into the mirror, then sing, in an operatic aria of your own creation, ‘I don’t think I shall ever get what I deserve, deserve, deserve.’ Keep singing until you can’t hold back your laughter.”
• or, to desensitize the “social phobic” male who is too anxious to meet “the right woman” to ever even make a date, to spend time alone during the week with four different women, e.g., “invite a fellow worker to join you for lunch, an elderly neighbor for dinner, a niece to the circus, and your mother out for dinner and a movie.”

A week or so, on the average, passes between successive e-mail sessions, a week in which the client will probably spend many hours in specific exercises or tasks and many more hours reflecting on them, consciously or not. From my comments, the client will, incidentally, learn more of the skills of “somat [or physical body] awareness”—subtle and rapid changes in sensations in the body which I view as prompts from, and paths to, the unconscious—and respond to these physical promptings of the unconscious in an increasingly optimal direction.

Each “session,” the client responds with reflections on the experience since the past “session,” and the therapist prepares another series of comments, challenges, and exercises for reflection. In my reply, I usually cut and paste the client’s message, and intersperse in it comments on specific points, e.g., “Really true?” or “How would you change this?” or “That is at odds with what you said on…” and, of course, the frequent “How and where did you sense that in your body?” and “Read your words again, slowly, and discover how it resonates in your mind and in your body.”

I encourage the client to preserve the entire process of therapy in chronological order on the hard disk, and also to file away a hard copy. The therapy process thus also creates a uniquely personalized self-improvement manual; the protocol, from beginning to end, is available at any time, and I encourage the client to read it and re-read it or just skim through it to gauge how far he has come.

Absent the face-to-face contact, I miss the opportunity to read body language—and body language is very important for me. In its place I have learned to heighten my sensitivity to nuances and subtleties of e-mail language, picking up variants, omissions, and circumlocutions of language that might have escaped me in an office visit. An occasional office visit, a brief telephone session, even a photograph from the client, can also help me form a better “picture.” (I avoid “instant” e-mail communication since this medium pressures both sides into speed and gives no opportunity for reflection.)

There are both advantages and drawbacks to distance counseling. The main advantage is in terms of expense: a session costs one-third to one-half as much as an office visit, no time or money is spent on traveling, and one session gives a week of “therapy.” The client proceeds at his own rate, but timing can be crucial. Not infrequently, when I delay a few days, the savvy client will come back to me with an interpretation or suggestions that accurately mimic the reply I was preparing. The client more and more develops his own resources and provides his own answers. It is excellent training in self-management and self-counseling often permitting a satisfactory termination in as

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little as five or six months, at a cost of less than $1,000. And the truly “personalized manual” is his to keep.

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