Azy Barak and Michal Wander-Schwartz
This paper was presented in S. A. King (Chair), Internet Support Groups: Group Therapy by E-mail and Chat, Symposium conducted at the annual convention of the American Psychological Association, Boston, August 1999. The authors are indebted to NetVision, an Israeli Internet Service Provider, for the donation of the Internet chat room and related programming. Correspondence concerning this paper should be addressed to Prof. Azy Barak, Department of Psychology, University of Haifa, Mount Carmel, Haifa 31905, Israel. E-mail: email@example.com
Computer-mediated interpersonal communication, enabled by Internet technology, has opened a new window of opportunity for psychologists interested in interactive therapeutic interventions. This possibility—having prospects and promises as well as risks and hazards (Childress, 1998)—has attracted a growing number of service-providing mental health professionals (Barak, 1999). The asynchronous communication option—made possible by e-mail and e-mail-based discussion groups and web-based forums for individual and group communication, respectively—has a major advantage: time and place elasticity. This technology, however, lacks a key feature of human interpersonal communication characterized by spontaneity, authenticity, immediacy, and directness. This feature is directly related to the commonly accepted and generally appreciated therapeutic factor of here and now. Numerous schools of psychotherapy argue that this immediacy factor may be responsible to a great degree for dramatic therapeutic developments. In addition, defense mechanisms or cognitive distortions (depending on school of therapy) are less likely to take place in a “here and now” therapeutic situation.
Nevertheless, cumulative evidence, from anecdotal reporting as well as from empirical studies, supports the use of asynchronous, Internet-based communication for both individual and group mental help (e.g., Barak, 1999; King & Moreggi, 1998; Murphey & Mitchel, 1998). Online group interventions have focused primarily on support groups in various areas of need, such as sexual abuse of women, cancer patients, and single parents. The clinical proposals for interventions, and actual interventions provided, have primarily been asynchronous. An exception are the attempts made by Suler (1996a, 1996b), who viewed and analyzed psychological opportunities at the Palace, an Internet-based multimedia, live chat environment. Therapy-focused groups, using synchronous (i.e., real-time) communication, however, have hardly been offered and, therefore, have not been subject to research to date. There might be two explanations for this: first, Internet chat rooms are relatively newer than e-mail distribution lists (listservs), and hence have had fewer opportunities to be used for therapeutic purposes. Second, from a technical point of view, web-based chat rooms have changed from the less reliable and less friendly HTML-based technology to advanced and efficient Java applications. In addition, the technology of password-protected chat rooms is relatively new. Suler (1999) listed several advantages offered by synchronous Internet communication: clear scheduling and definition of “meetings,” a feeling of presence, more spontaneous interactions resulting in more revealing disclosures, perceived commitment and dedication, and the inclusion of specific cues not present in asynchronous sessions (e.g., pauses in communication). He listed a few disadvantages as well: less convenience, and reduced time for responding and reflecting. The purpose of this study was to examine group therapy procedures that took place in an Internet, Java-based, password-protected chat room, and to compare its usefulness to a standard therapy group as well as to a no-treatment control group. We employed both quantitative and qualitative methods in examining the impact of the new intervention.
Participants were college students from several Israeli universities and community colleges who were recruited through newspaper and bulletin board ads that offered free group therapy to interested individuals. The ads mentioned both face-to-face and Internet chat room options, to be selected by the participant as preferred. Referrals were interviewed on the phone in order to screen out severe pathological cases and non-authentic referrals. The phone interviews inquired into a caller’s motivation for group therapy, past therapeutic experience, and general mental health parameters. After screening, six of the participants (three men and three women) selected were assigned to the Internet chat-room therapy group, and nine (three men and six women) to the standard face-to-face group. The size of the two groups was predetermined on the basis of an optimal group size desired for each intervention. A no-treatment control group of seven individuals (three men and four women) was made up of those who were deemed eligible but were unable to participate because of scheduling or other technical problems.
Participants in both intervention groups received time-limited, dynamically oriented therapy (Hudson-Allez, 1997; Wells, 1993). Therapy was provided by two female group therapists. Both therapists were similarly experienced professionals, in their 30s, and skillful in brief dynamic therapy. We preferred having two different therapists over a single therapist to prevent contaminating biasing effects. The therapist for the Internet chat-room group, in addition to her therapeutic skills, had reasonable personal experience in using the Internet and in participating in web chats.
Participants in the Internet-based group therapy met in a Java application, password- protected chat room for seven sessions of 90 minutes each. All sessions were held at a predetermined time—the same day and time every week. Graphically, the chat room had three scrolling screen windows: a vertical side window on which the nicknames of participants were shown, a large window on which all group message exchanges appeared, and on top of this one a smaller window on which the therapist’s messages appeared. Under the windows was a text box in which participants typed their messages. All participants in the chat room used nicknames, whether real or fabricated. At the beginning of the first session, the therapist provided a list of several specific rules in regard to communication and behavior (e.g., stay alone by the computer; use of certain code symbols to denote certain messages). Then the therapeutic communication began. Upon completion of each therapy session, we electronically saved the transcript of the group communication. The therapist used the transcripts after each session to analyze the group and to prepare for the next session. After the completion of the project, the transcripts were used to evaluate group processes.
Participants in the standard, face-to-face therapy group also met at a predetermined time in a convenient room on the campus of the University of Haifa.
Measures of Therapy Impact: Self-Esteem, Social Relationships, and Well-Being. These variables were measured by three scales taken from Hudson’s (1982) clinical measurement package. Each of these scales includes 25 items, to which respondents respond on 5-point scales. The Self-Esteem scale includes items such as: “I feel that others get along better than me.” The Social Relationships scale includes items such as “My friends are a source of joy for me.” The Well-Being scale (originally called Satisfaction Scale) includes items such as “I feel wonderful in the morning.” Cumulative empirical evidence highly supports the reliability and validity of measurement of these scales as efficient clinical measures.
Group Process Variables. We used a measure developed by Moose (1982) that includes 10 factors in the therapeutic group process: cohesiveness, action orientation, personal exposure, expression of feelings, expression of anger and aggression, independence, order and organization, newness, perceived therapist support, and perceived therapist control. Each scale is represented by nine items, to which respondents respond on a 6-point scale. The measure was found to be reliable and valid in previous research.
Evaluation Questionnaire. We constructed this questionnaire for the purpose of the study. It contained 11 items, each of which the participants had to rate on a 6-point scale. For example: “To what degree would you recommend participation in such a group to other people?” Total score was calculated by summing up all items. Four specific items were added to the Evaluation Questionnaire used with the chat-room group; these referred to their specific experience (e.g., “To what degree did anonymity influence your personal exposure to the group?” and “To what degree would you be interested to meet the other group members face-to-face?”).
Participants were given the research questionnaires approximately two weeks before the intervention started. The questionnaires were sent to and returned from the Internet and standard intervention group participants online and through regular mail, respectively. Participants continued with their regular lifestyle during the seven weeks of therapy; they were invited to contact us in cases of technical difficulties. Participants in the Internet-based therapy group commonly used their home computers, but were allowed to use any location they wished for connecting to the chat room. In several cases, participants in this group contacted us for technical reasons (e.g., difficulties in connecting to the Internet). In all cases, problems were solved satisfactorily. Upon completion of therapy, the research questionnaires were re-administered to the participants. Members of the no-treatment control group were administered the questionnaires at the same points in time as were the members of the therapy groups. Later, we independently interviewed the therapists in regard to their respective professional experiences.
Quantitative Analyses of Dependent Measures
Comparisons of the groups showed that both therapeutic groups had a small, statistically insignificant positive improvement in participants’ self-esteem, social relations, and well-being, though the virtual group showed slightly more improvement. Participants in the no-treatment control group generally remained unchanged. Slight differences were found between the two therapeutic groups after intervention, with an advantage to the Internet chat- room group. In terms of group processes as reported by participants, the two groups were found to be mostly similar in perceptions of group cohesiveness, personal exposure, expression of feelings, independence, and order and organization. Members of the Internet group, however, reported higher levels of aggression, action orientation, and therapist support and control.
The Evaluation Questionnaire revealed that participants in both groups expressed general satisfaction with their respective group therapies; there was no statistical difference here between the two groups. A review of the specific items administered to the participants of the chat-room-based therapy found that anonymity was a major factor in their readiness to open up. Furthermore, although participants in this group felt emotionally close to one another, they were not particularly interested in actually meeting the other group members.
Qualitative Analysis of Chat Room Transcripts
Because of the very small number of participants in each group and the idiosyncratic and phenomenological nature of group therapy, standard quantitative psychological research methods have limited validly in detecting real processes (Heppner, Kivlighan, & Wampold, 1999). Hence, we chose to analyze the chat room’s transcripts qualitatively in an attempt to identify cues to group therapeutic factors, processes and impact (Yalom, 1995). Hill, Thompson, and Williams’ (1997) consensual qualitative research system was employed for a qualitative analysis of the transcripts of the seven chat room sessions. Generally, we found evidence of growing messages of positive support, personal disclosures, interpersonal sensitivity, and group cohesiveness made by the participants during the course of therapy.
The therapists of the two treatment groups were generally satisfied with their respective groups. Both thought the groups had positive, constructive processes, generally similar to previous therapy groups that they had led. Both therapists, however, noted the very brief length of the group intervention and thought it was too time-limited to bring about a substantial and permanent change in participants. The chat-room therapist reported that her experience was similar in many factors, and different in others, to standard therapy groups that she had led. In addition to common therapeutic group factors that she noticed—such as cohesiveness, catharsis, leadership, disclosure, support, and aggression—she recognized much faster processes of interpersonal relationships, reflected in such various aspects as love and dislike, aggression, and support. She emphasized that her professional experience with the group was unique and very valuable; she felt much emotional involvement, and was very frustrated over the group’s early dissolution.
Although this study should be considered preliminary, and its findings should be handled carefully, it seems that an anonymous, Internet-based, chat-room group therapy is a legitimate method of psychological intervention and has a positive impact on interested individuals in need. The quantitative measures showed a trend toward positive change in terms of participants’ self-esteem, interpersonal relations, and well-being in comparison to the standard therapy and the no-treatment control groups. We believe that the statistical non-significance of these findings should be attributed mainly to the very small group size and apparently—as emerged from both participants and therapists’ feedback—from the limited number of sessions, as well. In terms of group dynamics, as reported by the participants, some of the group processes evinced by the two groups were similar, and others were different. Interestingly, the factors found to be different between the groups are consistent with those that characterize online group behavior (King & Moreggi, 1998). In terms of satisfaction with therapy, both groups were similarly partially satisfied. From a qualitative perspective, moreover, the chat-room group experienced therapeutic factors that typically exist in therapy groups. Taking all this evidence together, we may cautiously conclude that an Internet chat-room could be used for group-therapy purposes. Intensive research, however, is needed to further examine numerous professional and scientific questions in this regard, such as the preparation of therapists for this type of professional conduct, the rules by which groups ought to operate, and so on.
Barak, A. (1999). Psychological applications on the Internet: A discipline
on the threshold of a new millennium. Applied and Preventive Psychology,
Childress, C. (1998). Potential risks and benefits of online psychotherapeutic interventions [on-line]. Available (August, 1999): http://www.ismho.org/issues/9801.htm
Heppner, P. P., Kivlighan, D. M., & Wampold, B. E. (1999). Research design in counseling (2nd ed.). Belmont, CA: Wadsworth.
Hill, C., E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psychologist, 25, 517-572.
Hudson, W. W. (1982). The Clinical Measurement Package: A field manual. Homewood, IL: The Dorsey Press.
Hudson-Allez, G. (1997). Time-limited therapy in a general practice setting. London: Sage.
King, S. A., & Moreggi, D. (1998). Internet therapy and self help groups - the pros and cons. In J. Gackenbach (Ed.), Psychology and the Internet: Intrapersonal, interpersonal and transpersonal implications (pp. 77-109). San Diego, CA: Academic Press. Also available online (August, 1999): Also available online: http://www.concentric.net/~Astorm/Chapter5/index.html
Moose, R. H. (1981). Group Environment Scale Manual. Palo Alto, CA: Consulting Psychologists Press.
Murphy, L. J., & Mitchell, D. L. (1998). When writing helps to heal: e-mail as therapy. British Journal of Guidance and Counselling, 26, 21-32.
Suler, J. (1996a). Life at the palace: A cyberpsychology case study [on-line]. Available (August, 1999): http://www.rider.edu/users/suler/psycyber/palacestudy.html
Suler, J. (1996b). One of us: Participant observation research at The Palace [on-line]. Available (August, 1999): http://www.rider.edu/users/suler/psycyber/partobs.html
Suler, J. (1999). Psychotherapy in cyberspace [on-line]. Available (August, 1999): http://www.rider.edu/users/suler/psycyber/therapy.html
Wells, R. A. (1993). Clinical strategies in brief psychotherapy. In R. A. Wells & V. J. Giannetti, (Eds), Casebook of the brief psychotherapies. New York: Plenum.
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.