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Section 1
General Considerations for Online Therapy
Edited by Haim Weinberg and Arnon Rolnick
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1 Introduction to the General Consideration Section
Principles of Internet-based Treatment
Arnon Rolnick
Online Therapy
By Roni Frischoff
With a heavy heart I sit in front of the computer, waiting for her to connect through Skype.
Seven hours and an entire ocean separate us.
I accepted her plea to continue distance therapy, accompanying her first weeks of moving to a faraway country.
I always felt her as distant, unavailable, detached. I expect the technology to alienate us further.
I wish I had disagreed.
Leaning forward to see her better I click the connecting icon
Her face suddenly spread in front of me
Her big, glittering eyes, I can almost sense her breath.
A thin screen separates us
Just a kiss away
We begin this introduction by presenting two scripts from famous science-fiction art pieces: one from the novel The Naked Sun by Isaac Asimov, and the other from the movie Her.
In The Naked Sun, Asimov describes two possible forms of human interaction: Seeing, which means meeting face-to-face, and Viewing, which means encounters via technological devices.
A woman from another planet appears naked on the screen of an earthman who happens to be a policeman. The woman tells the policeman, Baley, that she would never do something like that in-person. Baley asks what the difference is between in-person and on-screen, saying to the woman that he can see her now, to which the woman responds:
āNo, you donāt see me. You see my image. Youāre viewing me.ā
āAnd that makes a difference?ā
āAll the difference there is.ā
****
In the movie Her the producer pursued a different futuristic concept of interaction that does not involve two humans, but rather a human-being and a computer. In an early conversation the human, Theodore, is told by the computer, Samantha, that she is made up of millions of personalities of the programmers who wrote her, but that she was also made to grow through experiences, just like a human. Later in the film, Theodore describes his relationship with Samantha in real, human terms, saying that at night when ātheyāreā in bed, he feels ācuddledā.
We chose these two futuristic pieces to trigger a discussion on how forms of interaction may be changing, and how the psychotherapy world is dealing with these changes.
This introductory chapter discusses how psychotherapy interacts with new technological developments. While it is true that the short history of this profession is replete with debates over what exactly constitutes psychotherapy ā modern technology and the Internet have certainly jarred the psychotherapy world like never before.
The possibility of using the Internet for psychotherapy confronts the therapeutic world with a fundamental dilemma. On one hand, it makes treatment accessible to populations that did not have access to psychological interventions beforehand and to individuals with problems that prevented them seeking such interventions. On the other hand, it threatens the conviction that genuine human contact is imperative for successful psychotherapy.
The review below demonstrates how theory and research in this field developed in very different directions, due to conflicting therapeutic approaches that often contradict one another.
We will attempt to show that the world of therapy has two significant aspects ā one that emphasizes the therapeutic relationship as the primary component in achieving change, and another that presents the therapeutic techniques as the central element.
As this book is intended for a relatively wide range of professionals including psychotherapists, group facilitators, and organizational consultants, we will begin with a brief overview of the world of psychotherapy.
Two Approaches to Psychotherapy
For many years, the world of psychotherapy has been divided into two different camps. The main difference between the two camps was their view of the curative factor in psychotherapy that might produce the desired change (cf. Omer and London, 1988).
We will refer to one group as the Techniques Camp, and to the other as the Relationship Camp. Each of these camps view different components as central towards bringing about changes, and therefore their attitudes toward remote treatment will differ from one another, as explained in the introduction.
The Techniques Camp
The techniques camp emphasizes the importance of the treatment method and defines treatment protocols in which certain interventions are emphasized as the generators of change. This is easy to demonstrate in cognitive behavioral therapy (CBT), in which there is a clear and well-defined series of interventions that define the principles of the method.
There are different examples of such interventions that demonstrate the extent to which the transition to telemedicine affects the methods used by the techniques camp. For example, a cognitive therapist is expected to identify automated thoughts, and to use them to identify key beliefs or organizing schemes that manage the patient. In order to identify these thoughts and beliefs, the therapist will apply techniques such as the āABCā model (A = Activating Event; B = Belief/thought; C = emotional and behavioral Consequence).
As its name suggests, this method also employs a series of behavioral interventions that are designed to improve the patientās condition. Methods of soothing the body through muscle relaxation have been fundamental techniques in CBT for many years. Although today there is a tendency to undervalue the importance of these components, they are still basic tools that therapists use. Upon entering the third generation of CBT, less of an effort was made to use these techniques. However, the acceptance approach and mindfulness ultimately emphasize both breathing and body scan.
In any case, this quick overview of CBT emphasizes the essence of the techniques camp. This leads us to the question of whether it is possible to translate these techniques for remote therapy and if so, how.
It is important to keep in mind that the techniques camp encompasses many other approaches beyond classic CBT. It includes approaches such as Acceptance and Commitment Therapy (ACT), as well as behavioral approaches such as DBT.
The Relationship Camp
Advocates of the relationship approach regard the therapeutic relationship as the curative factor that is the central facilitator of change. This camp maintains a series of assumptions about the origin and development of mental problems, which focuses particularly on the importance of the initial characters in the patientās life as designers of their worldview. It is assumed that an individualās central experiences as a child are those that shape his adult life. This approach is often considered to be inspired by Freudian thinking and his hypotheses about the necessary processes that the newborn undergoes while developing a relationship with parental figures. Over the years, this camp has evolved and now places great emphasis on the attachment processes, i.e. the extent to which the child experiences a pattern of secure attachment to the parental figure.
Thus, the relationship camp assumes that past relationships are the source of psychological problems in the present. Therefore, reconstructing those relationships and remedying them through a relationship with the therapist is the central component of therapy. Therapeutic approaches that explore the characteristics of the relationship between the patient and therapist were developed based on this assumption. This helps explain the development of concepts such as transference, i.e. how a patient relates to his therapist based on experiences with significant figures from the patientās past.
Dynamic therapists once placed a great deal of emphasis on interpreting relationships as ādiscovering the source of the patientās problem,ā however in recent years there has been an increasing tendency to perceive the patientās relationship with the therapist as therapeutic by itself.
Some of the central concepts that are often utilized by the relationship camp are āholdingā and ācontainingā. Though these terms have different meanings, both imply the importance of the supportive and accepting relationship. The relationship camp will then question whether holding and containing can be conveyed through Internet communication and impersonal screens.
How the Two Camps Use the Internet
The different approaches to Internet-based treatment that have been adopted by the two camps should not come as a surprise, as each camp has approached these developments in very different ways. In fact, there are significant publications about the use of Internet in psychotherapy, but each camp has developed its own approach to issues related to telemedicine that do not necessarily coincide with that of the other camp.
The techniques camp might have been expected to be the first to implement and document its application of remote interventions, as this camp is more likely to use technology than the relationship camp that sometimes attempts to detach the therapeutic process from the world of computers and telecommunication. Surprisingly though, the relationship camp was the first to begin writing about tele-therapy. As an anecdote, we might consider the fact that Freud would sometimes correspond with his patients though letters, which can be seen as the beginning of remote therapy.
The dynamic world has always been concerned with setting. Hundreds of articles have been written about the question of whether lying on the couch can be considered the same type of treatment as facing the therapist (cf. Grotstein, 1995). In other words, the question of the importance of face-to-face interaction has been pondered for many years.
Perhaps the first time that this camp dealt directly with remote therapy was when the telephone was introduced into the world of therapy. Therapists began to address the question of how to continue treatment when the patient traveled on business trips and was unable to visit the therapistās office (see Saul, 1951). This was a crucial issue, as therapists at that time believed that therapy sessions should take place four to five times per week. Psychoanalysis by phone, without seeing the patient, would most likely have been acceptable as it does not significantly differ from laying on the couch without eye contact between the patient and therapist.
However, there was significant opposition to the idea of using the phone for psychoanalysis. For example, Argentieri and Mehler (2003) represented the conservative-traditional stance that this could not be considered psychoanalysis but rather āonly a supportive treatmentā. Anyway, the need to teach psychoanalytic approaches and to train therapists in remote countries such as China caused some members of this camp to ābreak the rulesā and to dare to provide remote supervision and later even remote psychoanalysis for therapy students. Other developments were the introduction of Skype software which significantly improved the visual image, and the increasing speed of the Internet which enabled higher video density and thus better-quality communication. It is clear that the transition to remote treatment challenges certain fundamental dogmas and principles that characterize for the relationship camp, which explains the availability of vast literature and discussions on this option, and on the legitimacy of remote care via the Internet. Quite a few books have already been written on this subject. Distance Psychoanalysis (Carlino, 2011), Screen Relations (Russell, 2015), The Digital Age on the Couch (Lemma, 2017) and the special issue of Psychoanalytic Perspectives (2017). The most impressive enterprise on this subject is undoubtedly a series of four books published between 2013 and 2018, entitled Psychotherapy Online (Scharff, 2013, 2015, 2016, 2018). Each volume offers a fascinating discussion on the significance of remote treatment and how it affects the therapeutic relationship.
Despite the abundance of books and articles, very little quantitative research on this subject has been conducted so far in this camp. Qualitative analyses and even research on the attitudes of psychoanalysts about remote therapy are still lacking.
The techniques camp did not ignore the possibilities offered by the Internet but focused mainly on the possibility of adapting techniques that were developed for face-to-face therapy for online therapy, without addressing the question of how this may interfere with the development of the therapist-patient relationship. In Albert Ellisā introduction to Debrig-Palumbo and Zeineās book (2005) on online therapy, for example, he writes that āa big myth in psychotherapy is that, in order to relate well to your clients, you have to show them fine empathy, support, and acceptance, and you have to see them face to face ā Nonsense!ā (xi).
Therefore, it is not surprising to see that much of what has been done in the field has not focused on face-to-face video meetings but rather on transferring CBT techniques over the Internet. In fact, it might be possible to say that the main focus of the techniques camp is to find ways to make their proven methods more widespread by using the Internet.
Barak, Klein and Proudfoot (2009) identified the main areas of online psychological therapy. Videoconference is only one example, and perhaps a less common one of Barakās list. In any case, it is very important to see that thanks to the techniques camp, hundreds of studies emerged within several years on the various aspects of Internet-based treatment. Gerhard Andersson, editor of the āInternet Interventionsā, a leading journal in this field, writes that in just a few years there have been over 200 randomized control studies in this field (Andersson, 2018).
The Approach Taken by this Book
The editors of this book believe that many roads lead to Rome, and that many psychotherapeutic methods can contribute to an individualās well-being. Yet we do believe that providing therapy for another human being is completely different than using a computer-based self-help program. However, our approach is to seek interesting ways to integrate the principles of the techniques camp with those of the relationship camp.
Over recent years, more complex models of what is called āblended interventionsā have emerged. These are treatments that incorporate both face-to-face interaction and computer-based self-help programs (Fitzpatrick et al., 2018). Sometimes the face-to-face meetings are held while both the patient and the therapist are in the same room, but in principle a patient can see a therapist face-to-face online. The therapist can refer the patient to a site where he or she can practice behavioral cognitive methods, and once the patient has practiced them s/he will be able to return to the video ...
