Journal of Technology in Counseling

In recent years, hundreds of mental health chat rooms and bulletin board support groups have emerged (Cummings, Sproull, & Kiesler, 2002; Page, 2003). The growth of mental health online support groups has been characterized as an expansion of traditional mental health service (Perron, 2002). Potentially, a greater range of people with mental health concerns can be helped compared to the range of people helped when relying on strictly traditional face-to-face counseling methods. Researchers have sought to identify advantages and disadvantages of online self-help groups and the extent that the group therapeutic processes that operate in face-to-face group counseling can operate in online self-help groups (Finn, 1999; Gary & Remolino, 2000; Miller & Gergen, 1998).

Advantages for using online self-help groups include convenience, anonymity, inexpensiveness, and accessibility to people with common interests globally (Gary, 2001). The anonymity of online groups is especially attractive for individuals who have previously resisted peer support because of personal stigma or cultural reasons (Gary, 2001; Gary & Remolino, 2000). Disadvantages sited include the loss of nonverbal cues (Childress, 1998; DeGuzman & Ross, 1999; Galinsky, Schopler, & Abell, 1997; Salem, Bogat, & Reid, 1997), transience of member participation, and difficulty providing individual assistance to participants in crisis (Gary & Remolino, 2000). Additionally, the anonymity of the forum limits the ability to provide interpersonal feedback and hold members accountable for their behaviors (Miller & Gergen, 1998). Anonymity also makes it possible for users to perpetrate hoaxes of identity (Gary & Remolino, 2000).

Although anonymity has potential disadvantages (e.g., hoaxes, lack of accountability), anonymity has also been postulated as a primary mechanism of change for online groups (McKenna and Bargh, 1998; Suler, 2002). In a study of socially marginalized groups, McKenna and Bargh concluded that the presence of anonymity freed participants to explore their “true” selves without risking alienation from family and friends. The finding supported Suler’s (2002) online disinhibition effect, where anonymity increases exploration of perceived shameful secrets because the threats of undesirable repercussions in regular life are removed. To date, empirical investigations have not explained how the disadvantages are offset by the advantages of anonymity.

Other studies provide evidence that online self-help groups evince therapeutic processes that operate in face-to-face group counseling (Finn, 1999; Salem et al., 1997). One study examined benefits for online self-help group users coping with depression (Salem et al.). Using a random sampling of over 500 participants and 1,800 postings, Salem et al. identified two helping processes described as essential elements to therapeutic change in professional group therapy (Yalom, 1995): helping others (i.e., altruism) and advice or information exchanged (i.e., imparting information). In another study about online users coping with disabilities, Finn (1999) evaluated data with a content analysis and found evidence that five of Yalom’s 11 elements of therapeutic operated in online support groups: catharsis, universality, group cohesion, the providing of information (i.e., imparting of information), and of taking on the “helper role” (i.e., altruism). However, Finn also acknowledged a study limitation that the therapeutic conditions identified were based on “raters, not by the group members themselves” (p. 228) and recommended that “research that obtains information directly from group participants about their experiences in online groups is much needed” (p. 229).

The purpose of the current investigation was to one, seek clarification for how advantages and disadvantages impacted member use of online support groups and two, to identify which, if any advantages listed by users, suggested evidence for Yalom’s 11 group therapeutic factors. We believed that soliciting judgments directly from the people using the medium, as Finn recommended (1999), was a logical next step to help advance this research agenda. A qualitative approach of analysis best served the integrity of respondent judgments about online self-help groups.

After performing a search on Yahoo for self-help chat rooms/bulletin boards related to mental health concerns (e.g., depression, substance abuse), we asked permission to advertise our research project. Volunteers were solicited from the 130 self-help chat rooms/bulletin boards that permitted our research. Volunteers were linked to our webpage containing the consent form and survey. The consent form stated our purpose of learning their reactions and experiences with self-help chat rooms/bulletin boards. The survey required approximately 10-15 minutes and could be submitted electronically when completed. Although the anonymous submission of surveys prevented a calculation of response rate, Internet Cookies were used to detect duplicate responses originating from a particular computer and helped preserve validity of the responses received. We collected data over four months in the spring and summer, 2003. In all, 157 members volunteered for participation. The average respondent was 30.1 years old (Range: 13-74; S.D. = 14.9), female (78%), Caucasian (91%), unmarried (66%), had attended some college (41%), and earned less than $20,000 annually (44%).

The problems for which respondents sought online self-help groups were summarized in Table 1.

Descriptor	n
Presenting Problems
Depression	31
Eating Disorders	27
Medical Complications	23
Relationship Problems	18
Sexual Victimization (Assault, Rape, Abuse)	15
Panic/Anxiety	14
Self-Mutilation	13
Bipolar Disorder	11
Friendship/Loneliness	10
Parental	9
Other Anxiety (OCD, Social Anxiety)	9
Other (Gender Identity, Self-Esteem, Anger)	7
Addiction	6
Post Traumatic Stress Disorder Suicide and Self-Harm	5 4
Personality Disorder	3
Sex Concerns	2
Total	208

Of the 148 participants who typed a response for this question, 13 did not identify a problem and 4 did not provide a clear problem (e.g., “abuse”), leaving 131 respondent comments for analysis. For those 131 respondents, 208 problems were categorized. Although only about a third, 32% (n = 42) reported co-occurring concerns (e.g., eating disorder, relationship problems), most (i.e., 42 of 49, 86%) reported co-occurring concerns when depression and anxiety was the accompanying problem. The most frequent problems for which users sought support were depression, eating (i.e., bulimia, anorexia, or concerns about those problems), medical (e.g., aspartame poisoning, Paxil withdrawal), relationships (e.g., domestic violence, divorce, adoption), sexual victimization, and self-mutilation.

We used a basic interpretive qualitative approach to analyze participant perceptionsabout the advantages and disadvantages for using self-help Chat Room/Bulletin Boards. Categories were developed using the constant comparative method (Ary, Jacobs, Razavieh, & Sorensen, 2006). In the first phase, provisional coding of brief, concrete, recurring participant responses were selected (e.g., anonymity, cost). Coding in the first phase was conducted by two individuals, one of whom was the first author and the other an independent rater with a masters and specialists degree in counseling education. When a respondent identified multiple advantages/disadvantages, each one was categorized separately (e.g., vent, emotional support) unless the reasons or problems stated was alike (e.g., friendship and connection). Tentative categories were developed for clusters of related units of meaning (e.g., Universality). In the second coding phase, the second author independently rated responses and then reviewed codes developed in the first phase. For the first author only, categorization of the advantages and disadvantages was influenced by the online outcome literature (e.g., McKenna & Bargh, 1998; Suler, 2002) and categorization of group therapeutic factors was influenced by the 11 therapeutic factors set forth in Yalom (1995). The second author was influenced by background in group dynamics (Yalom, 1995). To improve dependability of the analysis, we estimated inter-rater agreement of categorization between the first and second author by randomly selecting 25% of the respondents for comparison. Inter-rater agreement for identically named categories for advantages was 31%, while similar units of meaning (e.g., Variety vs. Diversity; Disagreement vs. Conflict), had an inter-rater agreement of 83%. Discrepancies were resolved by consensus. Finally, we tallied each category.

Sociodemographic questionnaire (15-Items): The sociodemographic questionnaire consisted of nine fixed alternative questions (i.e., gender, annual income, ethnicity, education, marital status, time spent on bulletin boards, time spent in chat rooms, general time on the net, and counseling service history), and one fill-in-the-blank item for age. There were two checklist items, Reasons for Participating in Chat Room/Bulletin Boards (e.g., cost, convenience) and Previous Counseling History (e.g., individual, group counseling).

The first research question addressing the advantages and disadvantages for using online self-help groups from the user’s perspective are summarized in Tables 2 and 3, respectively. Of the 157 respondents, 134 described either advantages or disadvantages. Of those, two responses were ambiguous (e.g., “you don’t see the people face to face”), one was for a different purpose altogether (e.g., “used for sexual gratification”) and another only discussed the disadvantages of their face-to-face counselor. Those four respondents were excluded from the analysis, leaving 130 respondents (i.e., 83%) for categorization. In total, 349 responses were categorized, 261 as advantages (i.e., 75%) and 88 as disadvantages (i.e., 25%). Of the 261 responses categorized as advantages, 127 fit within Yalom’s framework of group therapeutic factors and 140 responses were categorized as advantages unique to groups online (see Table 2).

Six main categories of advantages were categorized for online self-help: Anonymity, Accessibility (i.e., convenience or expedience), Disinhibition, Diversity (i.e., members around the world), Cost/Affordability (i.e., free service), and sense of Autonomy for when and how much to respond. Of these six advantages, Anonymity and Acceptability accounted for 62% of the advantages reported by participants. Anonymity was multifaceted. It provided safety for online users:

The message boards let me really talk about what's going on without fearing running into someone on the street who ‘knows my secret.’

Anonymity was also linked to accounts of Disinhibition, as in “[it allows] for easier sharing of feelings”; and “you can discuss anything you feel is on your mind”.

In contrast to Anonymity, comments related to accessibility were straightforward and were typified by statements such as “[online support was] available 24/7” and “[there was] support of all kinds, no matter where you live.”

Autonomy referred to sense of control or ability to vary level of participation without suffering dire consequences for not participating:

[You can] pick and choose which threads to read and respond, if anyone should break my trust, I don't have to listen to them.

Eight disadvantages unique to the online method of interaction were identified (see Table 3).

The most frequent category was Identity Apprehension (i.e., the discomfort aroused when unsure whether the other users are who they say they are) and was related to another category, Maleficence (i.e., sarcastic, mean, harassing responses). One respondent summed up the problem of Identity Apprehension well:

If the board is public you have no idea who is reading your most personal information, could be a perpetrator or someone into rape fantasy, could be a ‘perp’ [perpetrator] posing as a survivor in order to find more victims, could also be a person posing as a therapist or other health professional; Also it’s very hard to trust people to know if they are telling you the truth or not.

The related problem, Maleficence, was succinctly explained by another respondent as an “Easy place to make sarcastic remarks without much possibility of repercussions.”

Impersonal Contact (i.e., distance separating those communicating; lack of eye contact, hugs, etc.) was the second most frequently reported disadvantage. As one participant said, “you can only say or share so much to someone who you have never seen face to face or have spoken to directly.” Absence of Therapy and Poor Guidance (i.e., misguided, misinformed, advice) were the next most frequent disadvantages. The Absence of Therapy was gleaned from comments such as, “Some people may think it is a substitute for therapy when it isn't, sometimes all you get is compassion, (they feel sorry for you) not real help.” Poor Guidance was described as misguided (“You have people who don't know what they're talking about giving advice.”), confused (“You can find the ramblings of a drugged up horse here rather than a clear answer.”) and rejecting (“you either fit in with the majority or you do not. If you do not, like any community, you are shunned...). Surprisingly, Loss of Nonverbal Communication Cues (e.g., “You lack the whole sensory layer of face-to-face social interaction”) was infrequently reported. Only four statements were made about the deficiency of loss of interpersonal cues (i.e., 1% of all responses categorized and 5% of the disadvantages categorized). Two less frequently occurring categories were Over-Reliance on the support group and Problems of Pragmatics in using the online medium (i.e., “it takes a great deal of time and research to find a good [site], where the people are truly interested in dealing with the subject the group is designed to deal with” [sic].

For our second research question, identifying the presence of Yalom’s 11 group therapeutic factors, we found evidence for five factors: Universality, Imparting of Information or Advice, Altruism, Catharsis, and Instillation of Hope. The most frequent category, Universality, accounted for 50% of the responses in this category and was reflected by the following responses:

Having others who understand and experience this is worth all the money in the world.

It can be relieving to meet others with common issues, and you can find out you are NOT ALONE with your problem.

These statements closely resembled Yalom’s (1995, p. 6) description of universality (i.e., “We’re all in the same boat”) as well as his account of its therapeutic value (i.e., “the disconfirmation of a patient’s feelings of uniqueness is a powerful source of relief”). Altruism, or receiving psychological benefit through the act of giving (Yalom, 1995), was also described by respondents, as follows:

I am able to reach out to those who are seeking a friendly ear to listen and be nderstanding of their situation. It is simply gratifying to pass on some of the coping tools I have learned and see some folks improving their lives because of contact through the web.

An exemplar of Instillation of Hope was described by one participant: “Many different people [were] at many different stages of healing. This was helpful to me because I could see that people do heal from rape and abuse.” The other three group therapeutic factors, Imparting of Information/Advice, Catharsis/Ventilation of emotions, and Acceptance were more straightforward and were characterized by responses like, “They [online support group members] are a great source of information, by getting me in touch with people who have already been there and hearing what they've learned from trial and error,” and “a chance to vent . . . .”

Partial support for the therapeutic factor, cohesiveness, was gleaned from responses expressing the feeling of support and nonjudgmental acceptance. However, because the responses did not also include descriptions about a feeling of belongingness, or “we-ness,” integral to Yalom’s definition of cohesiveness, we interpreted this as not fully representing the cohesiveness construct.

The primary purpose of the current study was to clarify how advantages and disadvantages impacted member use of online support groups. Results revealed that of about 350 participant responses categorized, far more responses (i.e., 75%) related to advantages and only a quarter of respondent comments related to disadvantages. Three frequently reported advantages, Universality, Anonymity, and Accessibility combined such that users were able to make anonymous contact with others with similar problems (i.e., universality) that might not otherwise be accessible to them (Finn, 1999; Sparks, 1992). Some respondents described experiencing greater comfort self-disclosing online compared to self-disclosing face-to-face and were able to self-disclose problems in less time compared to doing so in person. The role of anonymity for the online user in this study was consistent with Suler (2002), who suggested that anonymity conferred a sense of protection to the user freeing them from potentially stifling face-to-face interpersonal cues, such as a look of incredulity, boredom, or disapproval amid a difficult self-disclosure.

Five of the reported advantages were consistent with the helping processes described as the essential factors to therapeutic change in professional group therapy (Yalom, 1995): Universality, Catharsis, Instillation of Hope, Imparting Information and Altruism. Four of the five factors, Universality (Finn, 1999), Catharsis (Perron, 2002), and in different terms, Imparting Information and Altruism (Salem et al., 1997) have been reported in previous studies, providing credence to the findings in the present study. Universality was the most frequently reported of these five factors. Partial evidence was found for a sixth therapeutic process, Cohesiveness, in the current investigation, which is consistent with some previous reports (Finn; Gary & Remolino, 2000).

The number of disadvantages reported was a fraction of the advantages reported. Still, the respondents indeed highlighted a conflict induced by anonymity of the online nature of the interactions. On the one hand anonymity rendered self-disclosure psychologically safe, but on the other hand lacked the warmth of face-to-face contact (i.e., Impersonal Contact) and made it easier for people inclined to deceive others to perpetuate hoaxes (i.e., Maleficence & Identity Apprehension). As an example of the latter problem, one respondent in this study claimed that he/she used the service for “stimulation without significant guilt.” In spite of the disadvantages for the anonymity, one user summarized the conflict well: “even though these disadvantages are very serious, I feel that the advantages of a public board outweigh the disadvantages.”

Two surprising results also emerged from the data. Some members experienced a conflict related to participation of professional counselors in their forums. Some respondents desired professional advice and guidance; others only wanted to receive advice and guidance from people who had “been there.” The lack of professional guidance, or “hosting,” may have led to the development of cliques, misguided and misinformed advice-giving (i.e., Poor Guidance), and the allowance for pity rather than structured challenges (i.e., Absence of Therapy). The other surprising finding related to the loss of nonverbal cues. Only four statements out of 349 mentioned a problem of too few nonverbal cues. This finding is at odds with literature suggesting that loss of nonverbal cues is a significant shortcoming (Childress, 1998; DeGuzman & Ross, 1999; Galinsky et al., 1997; Gary & Remolino, 2000). Our findings may have differed from other studies partly because advantages and disadvantages were judged by users rather than researchers. Alternatively, our findings may have been due to lack of representativeness of our sample. Our data collection method, which relied on self-selection, may have contributed to the predominantly young, Caucasian Female sample. Further, we do not know how many online support group users disregarded our advertisement to participate, further restricting our findings to a unique subgroup of users and limiting the generalizability of these findings to other races, ethnicities, ages, or gender.

Because one of the disadvantages reported by respondents related to poor guidance offered by moderators or hosts, one way to promote the effectiveness of online support groups might be to have professional counselors assuming this leadership. Having professional counselors as hosts might also contribute to the level of therapeutic benefit conferred to participants. As reported in one study, group participants had greater satisfaction when leaders were perceived as more competent (Maton, 1988). Moderators, knowledgeable about and able to promote group factors, might deliver more effective online support. However, even without strong group leaders, it appears that members of online self-help groups believe that they have received psychotherapeutic benefits.

Page (2003) suggested that group leaders are uncomfortable with online formats groups because they equate group work with face-to-face interaction and as such, might have overlooked the advantages of online support groups. Professional counselors, however, might also look to the Internet and online support groups for ethical and productive uses of online formats (Miller & Gergen, 1998; Page, 2003). The findings of this study support such a charge for group leaders and other professionals committed to meeting mental health needs of their community.

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Todd W. Leibert, Ph.D., LMHC, Assistant Professor at Oakland University Sondra Smith-Adcock, Associate Professor, University of Florida and Joe Munson, Doctoral Student, University of Florida.

Correspondence concerning this article should be addressed to Todd W. Leibert, Oakland University, Department of Counseling, 2200 N. Squirrel Rd., Pawley Hall, Office #: 440K, Rochester, MI 48309-9929, Phone: (248) 370-2626, E-mail: leibert@oakland.edu