The Virtual Couch
For six years, Judy Griffith squirted hot glue on her skin, slashed herself with scalpels, and burned her body with screwdrivers that she had heated up on her stove. Wounding herself was the only way she had found to pull herself out of her deep depression. Sexually abused as a child, Griffith, 43, had seen a string of therapists, but they hadn't done much. One molested her, making it hard for her to trust the others. She was desperate for help. Finally, one hot summer afternoon two years ago, Griffith sought solace from her computer. Sitting at a small table in her dining room in remote Roy, Utah, she typed "counselors" into a Web search engine. Back came just one Web site, which led her to Peg Burr, a California therapist who agreed to treat her through e-mail.
Within weeks, Griffith had stopped the self-torture, and, within months, she no longer had flashbacks of sexual abuse. She feels better than she has in years, frequently rereading many of the 165 e-mail messages she has received from her online counselor. "A lot of therapists would think it's unethical to treat a patient with my problems over the Internet," Griffith says. But Burr "had the guts to try this, and I'm so grateful that she did."
Experiments with e-therapy are popping up all over cyberspace these days, as are debates over whether online counseling can do any good. Over the past two years, entirely new methods of treatment have developed using the Net, with thousands of Web sites making them available. There are educational sites, online clinics, services for teens in crisis, and programs to help workers get along better in their offices. Sites offer group therapy, video therapy, Freudian psychoanalysis via e-mail, even a psychiatrist who analyzes dreams for $13.50 each. Even big names are getting into the act. This fall, Joyce Brothers, one of the best-known psychologists in the U.S., is expected to launch her own Web site.
Breaking down barriers. The flood of online experimentation could ultimately transform the world of psychotherapy. New techniques are emerging that take advantage of the Web's instant-response features. And the Web's ability to break down barriers of geography could help make therapy more widely available. It's starting to happen. Britain's Dr. Russell Razzaque, one of the first psychiatrists to offer therapy on the Web, is now selling what is believed to be the first online Employee Assistance Program for corporations, in Britain and the U.S. For $36 per employee per year, a company can give its workers access to a variety of online therapy programs, at www.cyberanalysis.com.
Not everyone is rooting the cyber-analysts on. Indeed, some mainstream therapists deplore what's happening. Online therapy, they say, amounts to a dangerous gimmick that can easily harm vulnerable patients. They worry that unsuspecting patients will end up being treated by quacks. And they question whether patients can be helped at all if counselors can't see them and pick up on critical nonverbal cues. Even Burr acknowledges this medium isn't for everybody. She refers deeply troubled people to psychiatrists.
It's too early to know whether e-therapy's potential benefits outweigh the risks. Researchers are just beginning to study its effectiveness. Professors are planning courses. And professional societies are scrambling to take stands. "I don't want to squelch creativity, but it's our obligation to be cautious about something that's not proven," says Russ Newman, executive director of the American Psychological Assn.'s division on practice.
People with problems aren't waiting for official sanction. A recent Harris Poll says 24 million have sought mental-health info online. The National Institute of Mental Health Web site gets 150,000 visitors every day, but even less well-known sites are swamped. TeenCentral.Net, aimed at helping children in crisis, received nearly 12 million visitors during its first 18 months. Kids can get help on how to deal with crises like divorce and write stories to other teens about their problems--all screened by therapists. "We've stumbled onto something that's huge here," says Dr. James Feldman, public education director of KidsPeace, which developed the site.
Indeed, Judy Griffith's therapist, Burr, was astounded by the outcry for help. When she began offering people two free e-mail sessions in 1997 to try out her new service, she was bombarded with up to 30 e-mail replies a day. "I never knew the need was there," she says. But with the Web, all kinds of people with no previous access to psychotherapy suddenly find it easily available: those who work odd hours, live in rural areas, are too sick to travel, too busy to keep regular appointments, or just too embarrassed to set foot in a therapist's office. With therapists usually offering online sessions for less than their regular fees, many people can for the first time afford professional help.
Instant access. Judy Griffith was an extreme case. Burr at first thought Griffith might be too ill to be treated over the Internet. But Griffith, a homemaker who had become fascinated with computers as she traced her family genealogy, seemed exceptionally motivated. "The main reason I agreed was that I had no other resources that I could come up with for her," Burr says. Since Griffith had been sexually abused by a therapist, she didn't feel comfortable going to another counselor in person. "She had a very good reason not to trust," says Burr.
Griffith opened up to Burr quickly. It comforted her that Burr's Web site had a link to the California professional licensing board for psychology, so she could easily verify her credentials. And she liked the way Burr answered her first questions, making her feel respected, not just some sick person. She let Burr contact her primary-care doctor, who corroborated her medical and psychiatric history. And she sent Burr pictures, so the therapist could see the extent of her self-abuse: Scars covered much of her torso.
Burr became a lifeline. Griffith started writing her three e-mail messages a week, paying $30 for every response. She got each reply back within 24 hours, she says, and many were more than three pages long. She discovered that she preferred typing her feelings onto a computer screen. "I couldn't spill my guts in front of another human being," she says, always worrying about her appearance or her body language. She also liked being able to express her emotions whenever she wanted, rather than wait for a weekly face-to-face appointment. "It's easy to let it all out and then click and send," she says.
That's one major benefit of e-therapy: It makes people less self-conscious and more able to explore their feelings. "It was an amazing experience, one of the most profound relationships I've ever had," says Martha Ainsworth, a former e-therapy patient who runs Web sites about religion and online counseling. "I sometimes liken it to keeping a journal--but, in this case, the journal talks back to you." Paul Avila Mayer, a psychoanalyst who recently began conducting 50-minute chat sessions online through the here2listen.com Inc.'s clinic, says he has found that patients get into sensitive topics such as sex and aggression more quickly online.
The literal act of writing can be therapeutic in itself, many psychologists believe. The brain makes different types of neural connections when a person writes something down. Indeed, many conventional therapists encourage their patients to keep journals, and online psychiatrists like Razzaque now ask patients to keep e-mail diaries, sending entries every other day over the course of several weeks. Those electronic messages can help patients build on what they learn during sessions. They also have more time to consider the therapist's suggestions and interpretations.
Certainly, there are major disadvantages to online therapy. The main problem is lack of face-to-face contact. "So much goes on nonverbally in the course of a therapy session," says Laurie Young, a senior vice-president of the National Mental Health Assn. Besides facial expressions and tone of voice, she says, "it's important to evaluate the silences." To address such concerns, a few companies are offering therapy via video camera. Psychological Success Associates Inc. in Santa Clarita, Calif., launched videoshrink.com this summer.
Still, there's no denying the appeal of personal interactions. Even Judy Griffith, who was delighted with her e-mail therapy, decided after one month that she wanted to meet Peg Burr. "I wanted her to know my personality," she says. Griffith flew to Los Angeles and was initially relieved when she met Burr, sizing her up as someone she could trust. But when Burr made some small talk about her clothing, Griffith got mad. "Where is the therapist I've been talking to online?" she asked. "What happened to the amazing e-mail therapy?" Griffith saw Burr for three consecutive days and says she got some benefit out of it. But the sessions were nothing like the e-mails, she says. "Her e-mails were just awesome."
Burr has seen two other online clients in person, and she says they, too, were jolted by their face-to-face meetings. Some of the shock comes from the inevitable clash between expectations and reality, like the surprise people experience when they see a movie adaptation of a book they've read. And part of the difference is the pace of face-to-face therapy is much slower: with long pauses and, sometimes, lots of tears. Sharing such emotions can be therapeutic in itself, helping the patient feel safe dealing with painful feelings. "There's no way to do that with e-mail," Burr says.
After Griffith returned to Utah, her e-mail sessions resumed. Within four months, the flashbacks of abuse had come to an end, and a few months later, her depression started to lift. Every six months Griffith made a pilgrimage to Los Angeles to see her therapist in person. Now, after two years of counseling, the e-mail is down to one every week or so, and Griffith can contemplate the day when she may be well enough to end therapy. She worries though, that she'll miss Burr.
Endings are always hard, says Burr--even online. But, with e-therapy, at least the clients leave with a great parting gift: a written record of their psychological progress. "They get to walk away with a book of themselves," she says. And they know that if they need help again, it's just one click away.