Abstract
This qualitative study investigated whether
or not marital therapy can be conducted on the Internet using email. Mead's
symbolic interaction theory guided our observations. We hypothesized that in
the absence of "conversation of gestures," the email in itself may
serve as a therapeutic tool for increasing differentiation of thoughts from
emotions among highly reactive couples. With the help of eleven couples, we
found that in some cases email functions as hypothesized. We also discovered
a cathartic function for the email, which we termed ecatharsis. Brief,
solution-focused, strategic, structural, transactional analysis therapies
and Bowenian-differentiation therapy were useful in this modality. Some
couples reported that coaching and teaching helped them improve their
relationships.
In
1997 Leonard Holmes, an online counselor, posted an article on his web site
in which he expressed the sentiment of many when he claimed that online
counseling is not therapy. “While I do provide services directly to
clients over the Internet,” he wrote, “I have taken great pains to
distinguish what I do from therapy. Not everybody does the same.” In a
book on online mental health resources Grohol (1999) expressed a similar
sentiment:
Conducting
therapy online is a new experience fraught with difficulties and serious
concerns. As of this writing few of these concerns have been resolved
through professional association guidelines, state legislatures, or other
government bodies. This means, in effect, that you would be a virtual
pioneer if you choose to pursue this modality, and you may run into very
real ethical and legal problems (p.229).
Sampson, Kolodinsky, and Greeno (1997) documented the growing use of the
email by counselors who charge a fee for answering a question or for
conducting hour long chat sessions. Duncan and
Watts(1999) stressed the
importance of protecting client’s confidentiality, and the duty to warn as
these risks may increase on the Internet. Concerns with these matters have
lead to insightful publications which stress the importance of ethical
considerations and maintenance of professional standards for counselors on
the Internet (DuMez, 2000; Hackerman and Greer,
2000; Harris-Bowlsbey, 2000;
Hughes, 2000).
The demand for the Internet
services is expected to grow as the number of people with
relationship problems remains high (Talmon, 1993). The demand for
non-conventional services is driven by the fact that many couples may not
have the money, time, courage, or trust in mental health professionals to
seek conventional, face-to-face help. The logistic problems for couples and
families are even greater than for individuals: Palazzoli, Boscolo, Cecchin,
& Prata (1994), found it necessary to schedule only ten sessions at one
month intervals to accommodate clients' schedules. As a result of the demand
for counseling on the Internet, National Board for Certified Counselors
(1997) has established ethical guidelines specifically for counselors who
practice on the Internet.
While
the Internet eliminates scheduling problems, research is needed to learn how
to use this new modality. Because we are licensed marriage and family
therapists, we followed ethical guidelines for research established by the
American Association of Marriage and Family Therapists (1998). These
guidelines were general enough to apply even to research on marital therapy
using the email.
The
email system is characterized by asynchronous, written exchange of messages
in absence of face-to-face contacts. This modality (to be distinguished from
synchronous communication such as chat rooms, see-you-see-me, telephone, or
any other combination of audiovisual modalities) has already been
anticipated (Figley, 1985; Jedlicka, 1981) and described in the case of
relationship formation in absence of face-to-face initial contacts (Fox,
1995; Jedlicka, 1985).
The asynchronous communication allows
clients and therapists to pause and think without interference of gestures.
According to George Herbert Mead, gestures represent primordial
communication we share with other animals (Mead, 1934). In everyday life
humans mix words with “conversation of gestures.” This dual process of
communication tends to escalate emotions, may aid or hinder understanding,
and even deliver contradictory messages.
In the absence of gestures, the person is more likely to think, and
to focus and reason. When we have only words, thoughts rather than emotions
tend to dominate the discourse.
Mead’s
symbolic interactionism is echoed by Blumer
(1986) who sees human interaction
as an application of stabilized definitions. These definitions represent
mental imagery that merge in the minds of counselors and therapists as they
explore marital issues. Count-van
Manen (1991a, and 1991b) explores applications of Mead’s symbolic
interactionism as a framework for systemic counseling in general.
Mead's
distinction between primordial and advanced interaction is parallel to
Bowen's idea that “the behavior of all forms of life is driven and
regulated by the same fundamental life forces” (Kerr &
Bowen, 1988, p.
28). Both Bowen and Mead understood that rational thinking separates us from
other animals. When gestures are removed from the interaction, only words
are left. Therefore, we hypothesize that email can facilitate
differentiation by de-emphasizing the emotions and encouraging thinking.
Our
emphasis on communication is well within the accepted traditions of family
therapy. Communication theorists such as Don Jackson (1968),Jay
Haley,(1973)
and Virginia Satir (1967, 1972) have established a focus in family therapy
on how messages are sent and how they are received. Face-to-face, daily
communication between spouses often fails to communicate more than emotions
expressed through gestures and punctuated by words. The email, we
hypothesized, would minimize the “primordial” tendencies simply because
the medium excludes all gestures from the exchange. The email also seems to
allow clients to express their life narratives and upon reflecting on them
gain deeper self-understanding. In other words, instead of listening
to people narratives as Freedman and Combs (1996) and
de Shazer (1994)
propose, the therapist reads narratives, reflects upon them, perhaps
consults with co-therapist and then responds to the narrative.
We
explored these new counseling possibilities with the help of eleven,
anonymous, volunteer couples whom we recruited on the Internet. These
couples also helped us explore some basic questions that might help
professional agencies formulate guidelines and policies regarding therapies
on the Internet. We asked
whether marital therapy could be conducted on the Internet using email? If
so, who would be the appropriate clientele? And, what theories and
techniques could be used?
Working
with clients on the Internet for about six months, we were able to assess
our initial hypothesis and begin to clarify some of the issues implied in
the questions we asked. Our procedures and observations are presented below.
Methods
and Procedures
Recruitment
and Screening
After
the Human Subjects Investigation Committee at the University of Texas at
Tyler approved this project, we registered on Yahoo search engine a web site
announcing the online couple counseling project. Our web site described the
purpose and the procedures of the research project. Those interested in the
project were directed to these screening
questions:
Are
you currently living with a partner?
Do
you feel generally dissatisfied with your
relationship?
If
they answered “No” to either question they were directed to “exit”
with further explanation of why we cannot work with them. They were then
given general directions on seeking help locally.
If
they answered “Yes” to any of the following questions, they were also
directed to the exit with appropriate instructions to seek help locally or
elsewhere on the Internet:
Is
anyone in your household currently suicidal?
Is
anyone in the household making homicidal threats?
Is
either partner physically abusing the other?
Is
anyone in the family physically abusing a child?
Is
anyone in the family sexually abusing a child?
Are
you in therapy or counseling now?
We
do not know how many people were actually rejected through the prescreening
procedures.
Those
who qualified for the study were then directed to the informed consent page.
There, they could copy that page or request that we mail it to them. Before
a couple was accepted into the study, each partner had to sign the informed
consent form indicating that each understood the procedures.
Ethical
Considerations
Because
this was a research study, we followed the informed consent procedures that
meat the criteria established by the American Association of Marriage and
Family Therapists (1998). We obtained names, addresses, and telephone
numbers for each couple. We verified this information by telephone and mail
to assure that our participants can indeed be reached in case we had to
exercise the duty to warn.
The
clients were directed to the section on the Internet where the research
project and their participation in it was explained.
Only after visiting that page could they enter and print the informed
consent form. The form listed 7 items as follows:
1.
I understand that I am voluntarily participating in research, and that I may
withdraw my participation at any time.
2.
I understand that my name will not be revealed in any reports or
publications. Records will be identified by numbers only.
3.
I understand that there is a risk of loss of confidentiality due to the
Internet operations.
4.
I have been given an opportunity to ask any questions concerning my
participation in this study.
5.
I agree to participate jointly with my partner.
6.
I have read the project description and I consent to participate in this
project.
7.
If I have any questions concerning my participation in this project, I shall
contact Dr. Davor Jedlicka at (telephone number) or by email. If I have any
questions concerning my rights as a research participant, I shall contact (
telephone and name of the chair of the Human Subjects Investigation
Committee at the University of Texas at Tyler).
The
description of the research project described the purpose of the study, how
to initiate the study, who are the researchers, and how they will work
together. One researcher’s role was that of a therapist and the other
served as a supervisor.
Supervisory
Procedures
We developed supervisory procedures based on the
standards of the American Association for Marriage and Family Therapy (Todd
& Storm, 1997). While we had to experiment with supervisory procedures,
each case was supervised on and off line.
The
email between the therapist and the client was stored on the therapist’s
computer for the duration of the study. In addition each email sent and
received was printed and stored in a folder for each couple. The left side
of the folder included the contact sheet. The contact sheet is a form on
which the date of each email sent and received was recorded. The right side
of the folder included chronologically ordered exchange of email. This
folder was presented to the supervisor during the weekly face-to-face
supervisory sessions.
In
addition to the traditional supervision, we also practiced online
supervision. Sometimes the supervisee forwarded certain email messages to
the supervisor for immediate advice before answering the subject’s email.
We found this method of supervision more flexible and more responsive to
client’s needs than the more structured traditional face-to-face
supervisory method.
Couples
We
include here each couple that sent at least one email after we received an
acceptable informed consent. For
about six months from the time we posted the web site to the conclusion of
the last case, we accepted eleven couples. We also include an encounter with
a subject whose email raised some ethical questions.
Therapy
started with a routine initial assessment using an online questionnaire. We
collected some demographic data that gave us the age range from 24 through
53. Incomes tended to be above average. Four couples reported combined
incomes of over $60,000 per year. Only one couple reported their income to
be below $20,000 annually. Occupations included a truck driver, an
executive, clinical therapist, program analyst, teacher, crisis counselor,
food service manager, and photo lab technician among men. Among women
participants were a housewife, a student, social workers, an attorney, a
sales person, and a bartender. Not all participants gave us all of the
background information, and we did not insist that they do so.
Inquiries
were made about their previous experience with counseling. We considered a
couple to be experienced if either of them had ever been in counseling
before. By this definition seven couples were “experienced.” Their
previous counseling experience and duration of Internet sessions were as
follows:
Couple
#
Duration of
______
Therapy in Days Previous
Counseling
2
69
Yes
3
67
Yes
4
63
No
5
62
No
6
35
Yes
7
20
Yes
8
15
No
9
8
Yes
10
5
Yes
11
4
No
Our
initial question did not ascertain whether their previous experience with
counseling included online counseling. However, in every case we double
checked that whatever counseling they experienced had actually terminated.
In each case they assured us that their counseling relations were
terminated, and we also learned that not even one couple had any previous
experience with online counseling.
Duration
of Therapy
Duration of participants therapy was measured from the date of the
first email received until the date of the last email received. If the
participants did not respond within any seven days, a follow-up email was
sent. If at that time they informed us that they were no longer involved
with the project, the termination date was based on the date of the email
received from the client prior to the inquiry.
The
longest time span we measured was 98 days (14 weeks) of continuous weekly
participation by both spouses. We were committed to respond no later that
three days after we received their email. Because we had a small number of
clients, most of the time we would respond within a day or two.
Counseling
Procedures
The
clients were accepted for five months. After that we closed the web site. It
took an additional one month to completely close the last case. The study
began when we received the first informed consent.
Following the receipt of the informed consent, we sent a welcome
email and instructions to access the initial questionnaire. The last item of
the questionnaire was an open-ended question for “comments.” Some of
them took this opportunity to begin presenting their problems. The
participants seemed to appreciate being able to get to the point with a
minimum of initiation rituals. The induction was over when we received the
reply to our email that included two questions:
1) Each of
you please tell me about your situation now, and 2) What do you want from
your relationship? The date of their answer to that email counted as the
beginning of the session even if only one of them replied.
Sometimes
our initial questions were sufficient to evoke a two or three thousand word
responses. Spouses tended to differ in their openness, their degree of
parsimony, their willingness to participate, and in the frequency with which
they sent us email. We let each spouse write as much as they wanted and as
frequently as they wanted. We commented only if we did not hear from one of
them for at least one week. Termination was by mutual agreement.
The
counseling methods used depended on the presenting problems. We remained
flexible through out without becoming committed to any one theoretical
perspective. The asynchronous nature of the communication allowed us time to
think, consult with the supervisor, and to ask the clients for
clarifications before we planned therapeutic interventions. The nature and
the outcome of interventions in each case are presented below.
Case Summaries
Couple
1
This
couple stayed online for over four months, because they had more than one
problem. In the first message from them the husband wrote, “The biggest
point of frustration for me is money. I get stressed about bills and my wife
wants to know why I can't make love to her.”
By
the third week we learned that every time they saved some money, the wife
would use it to visit her family in the country of her origin. We suspected
that the husband resented these trips because the wife had romantic
attachments there before she married him. Whenever her
trips were discussed, he would go into a non-violent rage over money.
Yet he was not outraged when his wife planned a trip to visit a relative in
another state, even though the cost was almost equal.
This therapy was further complicated by the wife's
lack of involvement with family budgeting and planning. The husband did not
ask her to become involved, but he often complained about her “lack of
respect for the dollar.” During
therapy she decided to “learn how to budget” and keep track of the
money. We coached the couple on how to create a cooperative budget without
anger. The husband's budgeting was detailed to the penny while the wife
never had kept any records at all.
The
husband calmed down immensely when his wife agreed to postpone her trips
abroad until they saved enough money to buy a house. Their sex life
improved, and they reported being happier.
The
improvement in one area made things worse in another. As an immigrant, the
wife was struggling with defining her ethnic identity. Even though she
became an American citizen, she did not feel that she belonged anywhere.
Visits to the country of her origin gave her a feeling of belonging and a
sense of identity. Generally, people with foreign accents are often treated
as visitors, passing through on the way out of the country. We wrote about
the meaning of the American nationality and her own role in deciding who she
is and where she belonged. We also helped the husband find a role in the
process of acculturation of his wife.
At
the end of therapy, they were both appreciative, and their situation clearly
improved. They reported increased frequency and satisfaction with their sex
life. They were working together to buy a new house, and the wife was
beginning to shape her new identity as an American. Our therapy consisted of
restructuring family roles around money management, coaching in cooperative
methods of budgeting and planning, and education on citizenship and
identity. Therapy also included coaching them to be less emotionally
reactive with each other and to self-soothe.
Couple
2
At
the time this couple contacted us they were contemplating divorce. They
described their main disagreement as "when, where, and how to have
sex." The wife agreed to certain unusual sexual practices before they
married, and changed her mind within a month after marriage. In over two
thousand words per message, unresolved issues of jealousy, broken
expectations, and mistrust were revealed. They told their life stories in
minute and copious detail. Their narratives were repetitious, broad, and
without a focus. Each time they were asked to be specific, the impasse in
the present always came back to the differences in their expectation about
sex-life. When they tried to resolve their sex problems, they would become
reactive over issues dating from before their marriage. After more than a
year of arguments, and a year of individual therapy for the husband, there
had been no progress in their relationship. (Incidentally, we verified that
at the time they signed the informed consent neither of them was in therapy
anywhere else.) In fact, the same cycle was beginning to repeat on the
Internet.
We
helped them break the cycle by inducing them to shift the focus from the
past to the present. We used their exact words from the previous email
messages to construct a most negative image of them. We then presented that
image to convey our understanding of them now.
Their
response was swift, and defensive. They now used
long messages to convince us that things “were not quite as bad as
we made you think.” They explained in detail that they were not bad
people, that they had a lot of good characteristics and that in spite of our
impressions, they did care for each other and for the wife’s son from a
previous marriage. They also put the past into a more reasonable
perspective, leaving them with a difficult, unresolved problem about their
present sex life. Quickly they realized that however they resolved their
sexual difficulty, it would have to be their own decision. Without
prompting, they also agreed to remain respectful of each other even if they
decided to divorce over their disagreements.
After
two months, at the time of termination, they practiced conventional sex more
frequently (whatever that means for them). Their anxiety was reduced,
reactivity diminished to the point where they could discuss sensitive issues
without going back in time to justify their current views. They were being
less emotionally reactive with each other and seemed to be more thoughtful
in their interactions.
Couple
3
Therapy began with a 1500 word message from the wife. She expressed
hurt feelings, anger, and frustration. Her messages suggested a great deal
of anxiety and difficulty in separating thinking and feeling. She used
phrases like “I am always angry,” and “He never listens to me.” The
husband also wrote over a thousand words, of what we think represents an
online catharsis, or ecatharsis. In his message one phrase caught our
attention, “My love is so strong that the only way she could doubt it is
through misunderstanding or over-sensitivity.”
In
this case we created a paradox by prescribing the symptom. We noticed that
in the early messages the wife used the phrase “stress points” which
made her “always angry.” We already had attempted to defuse such
reasoning, but this time we asked both of them to schedule their “stress
points” so that they could gain control over them. The wife was put in
charge of that task because that was her metaphor. After a week, she sent a
short message informing us that our intervention did not work. She wrote,
“scheduling of stress points does not work for us. It requires a
causal event that does not happen that often. So it did not happen.” When
it did happen before, she told us that “my husband makes me” go into
violent rage during which she would break things around the house. We also
learned that he would withdraw during these episodes and that she never
threw anything at him.
We
asked them to try harder to bring about one of these episodes, and when the
episode occurs, instead of breaking things that she immediately writes to
us. “Try harder next week,” we wrote, “and ask your husband to help
you bring about a causal event.”
Next
week the husband accidentally called her by his ex-wife's first name. In his
wife's thinking this ranked on the top of provocative “causal events.”
They both wrote to us and informed us of the tense situation in their
household. This time, however, she did not go into a rage even though she
told us that she was as upset as ever. It appeared that she was beginning to
distinguish between her feeling and thinking processes. Instead she stayed
quiet for three days, not to punish the husband, but to calm herself and to
think through her thoughts. The husband left her alone with no complaints,
and was amazed that the glasses did not fly around the house and that his
apology did not lead to a long shouting match.
When
we terminated therapy with this couple, they felt that it was not likely
that they would relapse into rage. We were under the impression that they
had learned to think reflexively, to question their own emotions, act
reflectively, and consider the other person's perception of the self. It
appeared that both were thinking more and reacting less.
Couple
4
In
this case both spouses had previously been in individual counseling. They
appreciated the Internet therapy because they could "get right to the
point" even in their first email. Throughout therapy, this couple
always sent one message together; the first part of the message was hers,
and the second his. What
fascinated us about this, is that they wrote about each other, and about
sensitive issues as if neither of them was there to observe. It seemed as if
the email process reduced the emotional reactiveness and somehow prevented
them from infecting each other with anxiety.
Below
are excerpts from the first message they wrote:
She: “I started taking the birth control pill back in
October and since then my libido has waned significantly. I used to be very
sexually aggressive but now I just feel tired and not as aroused as I was
before. I know he is very concerned and upset with this situation. I would
like to have a smooth relationship where he and I can tell each other
anything and everything.”
She went
on to explain how their conversations quickly degenerate into shouting and
hurt feelings.
He: “I feel that about 99% of our arguments arise from me
not telling her how I feel or how something she does or says affects me
emotionally. Instead I lash out with mean things to say. Sex has been a
problem lately. Her lack of interest frustrates me.”
In
that message he continued to express how much he loved his wife, and that
everything he did he did for “her interest.” We noticed that each week
he kept repeating the same two phrases “I only do things for her best
interest,” and “I am only looking out for her best interest.” At the
same time, their sex life was not improving. Attempts to help them
differentiate by asking them to let each define her/his own “best
interest” did not provide much difference. She seemed to support his
thinking about “her best interest,” and he never seemed to have enough
of thinking about “her best interest.”
After
a month of emailing, it appeared that they could write indefinitely about
the same issues using different words, yet never indicate that anything was
changing much in their relationship. We decided, therefore, to try a more
drastic intervention. After awhile, we posed this question to them:
“Wouldn't you agree that if one treats an adult like a child, sex is like
being molested by a pedophile?”
That
question evoked a fury of email asking us for explanations, and
clarifications. Then there were denials by both of them. We responded by
providing transactional analysis of their own email. The wife was the first
to relax and ponder their fusion. She noticed the reduction in tension, and
improvement in their demeanor toward each other. Even though we explained
how each has a role in developing the type of relationship, the husband felt
that our comment was directed only toward him. He showed no antagonism
toward us, but he continued to explain “his innocence.” At the end of
therapy, they reported that their sex life had improved, and that they were
planning a romantic vacation, while still struggling with the
“pedophilia” interpretation. Their
last message to us included this:
She: “I
want to let you know that we are going on vacation for a few weeks. We will
continue talking about the question you posed to us. While we are on our
travels, if we come across Internet access, we will email you with any
question we may have. But otherwise, I believe the time we have together
will enable us to discuss and find some answers.”
In
the same message, he wrote, “I want to clarify again what I meant by
“her best interest. . . . ”
Judging
from their initial email, no one could imagine that this couple could take a
trip together in eight weeks. We
think our interventions contributed to this change. The reframing of their
situation certainly changed their thinking. We also found transactional
analysis a convenient tool to illustrate to the clients how we came to such
a drastic view of their situation.
Couple
5
One
of our “long-term” cases was not successful. After two months of our
involvement with the couple, we could not detect a change in their
relationship. Perhaps they enjoyed the opportunity to write one to two
thousand word messages two or three times per week, but each spouse's email
continued to focus on the other. Each was so convinced that the other was
the culprit, that they thought of our input as reflecting
“a failure to understand their situation.”
After four weeks we wrote that
whether we understand their situation or not, we do not know what to do to
help them change. We also recommended that they try face-to-face counseling
in their community:
In
response to that suggestion they wrote,
“We do not want to end--I think we just need you to take
control of the situation since you're the one with the expertise, and we
don't know what we should be providing you. Perhaps some suggestions from
you on how we can make our sessions more effective would be good. I think we
need to give this a fair chance before concluding that email is not the
answer for us. Please don't give up, we need your assistance and feel this
method has potential, given time and effort. Are there only specific types
of couples that best suit online counseling?”
We acknowledged not knowing the
answers to their questions, however, we did stay with them for another four
weeks. They were not satisfied with us because “we did not take charge.”
We explained that we did not know how to take charge of them in a way that
would help their relationship. Eventually
they accepted our limitations and they agreed to seek help in face-to-face
therapy in their community.
Couple
6
This
couple changed swiftly. They came right to the point in the first email.
Their messages were always between 250 and 500 words. She wrote,
“we seem to fight about everything,” “I try to put all this baggage
behind but I can’t.” Fighting was daily, mainly her shouting, yelling,
breaking things, and the husband cowering quietly. She interpreted his tempo
and his demeanor as an affront to her. Therefore, when he did not meet her
expectations of doing something fast enough, she would interpret his actions
as a deliberate provocation.
The
first day of therapy we instructed her that each time “your husband makes
you angry” to say or do nothing except go to the computer and write to us
how “he made you angry this time.” She did that every day for a week.
She even became angry with him for taking three days to answer our initial
inquiry, when she answered it immediately. Each day he delayed she was more and more furious, writing us
each day, sometimes more than once. We encouraged her to stay calm, manage
her anxiety, soothe herself, keep writing, and say nothing at all to her
husband about her anger. In her writing to us she referred to him with
insulting names which only last week she would had told him directly.
After
the third day he wrote, “Sorry, it took for me so long to reply after
filling in the questionnaire and getting my first email.”
He apologized for being slow, and promised to be more prompt in the
future. He ignored the fact that our guidelines gave him seven days to
respond.
Actually, it was difficult to keep up with this couple. But because
we had only two or three clients at a time, we could respond to their email
daily. We learned that long ago he used to treat his wife “like dirt”
but that he no longer does that and she won't forgive him.
She kept repeating the phrase “like dirt” as if she wanted us to
ask more about that. We acknowledged reading her grievance, and moved on to
education and solution focused interventions. We helped them to see that the
different sense of timing people have is an individual trait, and not an
instrument of disrespect. We then focused them on the present, and inquired
about their worthwhile experiences.
The
email in itself was an indispensable therapeutic tool for this couple. Her
anger did not subside immediately, but within five weeks she separated her
anger (feelings) from her thinking and behavior. She seemed to have achieved
a level of differentiation that allowed this couple for the first time to
talk about current issues without becoming reactive. When the feeling of
anger and an urge to lash out at him would come, she would go to her
computer and send us an email. After the second week she wrote less
frequently. They became calmer, and did not need us any more. The second
week after the therapy began, the husband wrote, “By the way the last few
days have been pretty great for me in this relationship. We haven't argued
at all! She seems to be happier and she even told me so. I just hope she
isn't hiding the truth from me.”
She
was not hiding anything. Her anger subsided after years of daily
bickering and arguments that sometimes resulted in the wife breaking glasses
and plates. They claimed that dozens of hours previously in individual
counseling had not helped them. Before their Internet therapy the wife was
sending the husband to therapy for his “passive aggression,” and he was
sending her to counseling for “anger management.”
After
the fifth week, they were convinced that their relationship had changed. The
email stopped coming, and in response to our last inquiry, they informed us
that they are calm and happy. They concluded saying, “as always, thank you
for your time and honest concern about us.”
Couple
7
This
couple was approaching retirement. They reported general dissatisfaction
with their relationship but they did not know why or what to do about it.
They argued almost daily. When asked initially, “What do you want from
your relationship?” they were stuck. The three weeks of therapy consisted of them coming up with a
joint answer to that question. After
about three weeks they together formed the following statement:
“We want
to enjoy our retirement and time together more. We need to establish working
roles for housework. Talk without arguing; establish a working relationship
for projects and work through them without trauma.”
By coming
up with that statement within three weeks, they had already demonstrated to
themselves that they can “talk without arguing” and without
“trauma.” They reported being confident that they can stay focused and
work out the details of their agreement without anyone's help.
The
remaining couples
Three
of the four remaining couples chose to seek face-to-face counseling in their
communities. One couple took two weeks to decide that they each wanted
conventional counseling. Others took even less time to decide.
One
couple terminated in four days. After sending in the informed consent signed
by both, after each had completed an online questionnaire and responded to
the initial inquiry, the husband wrote “we are not ready for email therapy
now. Please remove us from your study.” We thanked them, and encouraged
them to seek help locally. Next day we heard from the wife, she wanted to
continue therapy but her husband would not let her, and we were not willing
to work with only one spouse. She explained that she cheated on her husband
once, and that he never forgave her. “He does not want a divorce, but he
does not want to solve the problem either.”
The
remaining couples also went through all of the initial procedures, and then
informed us that they preferred to find someone in their community. They
were exploring the possibility of Internet therapy, but for a reason they
did not share with us, decided that this modality was not for them.
Additional
Ethical Issues
We
were confident that our methods followed ethical procedures according to the
guidelines of the American Association for Marriage and Family Therapy, and
the federal guidelines for ethical research enforced by the Human Subjects
Investigation Committee at the University of Texas at Tyler. Nevertheless,
we encountered an unanticipated ethical dilemma presented in the following
email:
I am very emotional person who has anger management
problems. When I'm angry, I yell and throw things. I've talked to counselors
to work on this problem. My husband of less than two years, although he says
he's supportive, is constantly and intentionally setting me off by trying to
control me, calling me names and criticizing me. I work for his home-based
business and he uses this to “boss” me and “lead” me.
I am not comfortable with working for him
because I am far too sensitive to deal with his management style. He
yells that he's providing for our family but won't allow me to work outside
of his business. I am reacting to his controlling,
insensitive ways by yelling, crying, and breaking things around the
house. I love him but feel emotionally abused. I'm trying to work on my
problems but don't have the support and understanding I need from him. Is it
possible to save this relationship or should I run and save myself?
When we received this message we knew
that our open email access could prevent the outward expression of rage and
allow clients to discover new ways of dealing with the spouse and with their
emotions. However, we did not intervene with this couple because they were
not screened on our web site. We offered to work with her and her husband if
they would both send in the informed consent. He refused to participate, so
we suggested counseling in her community (which apparently she did before
contacting us). We also directed her to a few other online sites that
specialized in individual counseling that might be willing to work with her
alone.
What
we discovered through this case, is that no matter how tight the screening
procedure, on the Internet anyone can initiate contact anytime they want to
without going through the established procedures. The dilemma becomes, if
therapists think they can help such people, is it ethical to turn them down
without anything more than a referral? And, is it ethical to refer them to
web sites that are operated by therapists unknown to the referring
therapist, whose methods and procedures are unknown, and whose
qualifications are unknown or difficult to verify?
Discussion and Conclusion
We
started this study with a question: Can marital therapy be conducted on the
Internet using only email? To answer that question we analyzed our
experiences with eleven couples within the context of Mead's symbolic
interactionism (Mead, 1934). According to Mead it is important to
distinguish the “conversation of gestures” from “the use of
significant symbols.” The reaction to gestures is on the primordial level
of communication that we share with other animals.
In
talk therapy the words, the significant symbols, and gestures, are mixed. On
the Internet, on the other hand, we found that, the medium controls the
process. Because some clients prefer to nurture their emotions rather than
to think, they might find email therapy unappealing. We found that our
clients who accepted thinking
and problem solving benefited on the Internet as well as could be expected
in face-to-face therapy. In fact, given that some couples were initially
highly reactive, fused, and generally lacked differentiation; in our
judgment, for some of them, email therapy can accomplish the same ends in a
shorter time.
We
acknowledge that our screening excluded the most difficult cases. No one in
our sample was abusing anyone physically, children were not directly
involved, and most of our clients had previous experience with therapy. One
could argue that we simply continued where some other therapists left off.
Or, we could hypothesize that in some cases the email therapy provided a new
method for change. We cannot answer these questions in one study. However,
we conclude, without hesitation, that our experience with online-clients
qualifies as marital therapy.
Until
we know more about this type of therapy, we recommend strict screening
procedures and the use of interventions that we found applicable in this
study. It is likely, however, that other interventions might work also.
Until
additional research demonstrates applicability of other interventions, we
found that brief, solution-focused, strategic techniques as practiced by
Chevalier (1995), Cade and O'Hanlon
(1993), Miller, Hubble, and Duncan
(1996), O'Hanlon and Weiner-Davis (1989),
Talmon (1990), and Walter and
Peller (1992), can be effective in producing rapid change in the lives of
couples having difficulties in their marriages. We have used in this study
Haley's (1976) and Madanes' (1981) strategic techniques such as
reframing, exaggerating, and setting paradoxes, to reduce enmeshment, and to focus clients' thinking on the
present.
Coaching
and teaching also help clients
learn specific tasks such as preparing a budget, planning retirement
together, understanding the meaning of American citizenship, and involving
the American-born spouse to help acculturate the immigrant spouse.
We
also used transactional analysis (Steiner, 1990;
Stewart, 1996). When a
couple challenged our interpretation of their situation, we needed time to
develop an answer. In asynchronous modality, we had time to review
transactional theory, and to extract excerpts from a number of earlier
messages. We then submitted the compiled information for the clients' own
analysis. This procedure was similar to playing a video from a previous
session, with more flexibility in extracting and quickly reviewing previous
sessions.
In
cases of couples entangled in family-role confusion, structural therapy (Minuchin,
1974) helped clarify roles and
establish boundaries. Finally, we encouraged narrative applications
following the therapies of de Shazer (1994) and
Freedman and Combs (1996).
We encouraged couples to construct narratives that were most helpful to
them, we helped them separate problems from their identity, and encouraged
them to construct new narratives. However, these narratives tended to dwell
in the past. We found that we could mix narrative with strategic
interventions to expedite change in orientation from the past to the
present.
As
we hypothesized, the email in itself can be therapeutic. Some clients used
the email to divert aggression, to reduce the tension between the pair, and
to stabilize the relationship until the couple either resolves the problem
or finds alternative ways of dealing with it.
It
appears that internet therapy may reduce the anxiety that could interfere
with the effectiveness of the talk
therapy. Therapy on the Internet also tends to
reduces the anxiety that the therapist must deal with in face-to-face
talk therapy. This modality allows the therapist greater emotional distance,
thus it may aid the therapist in staying out of triangles. Internet therapy
allows the therapist more time to examine her/his input to the clients. Thus
internet therapy may facilitate better thought out interventions by
therapists.
The
use of email therapy may provide some of the advantages that clients often
experience through journaling. Journaling often facilitates clients seeing
their life quite differently and especially seeing their part at a distance.
Email therapy may help some clients to see their part in problems more
objectively.
We suspect that the email can also be
cathartic. We refer to this
phenomenon as ecatharsis. The client expresses the anger toward the
spouse in the email, thereby avoiding face-to-face confrontation. Because
ecatharses can go on for days and weeks, eventually the client is relieved,
and the relationship seems to improve. This aspect of the email therapy has
its own therapeutic value that cannot be replicated in the office-based or
telephone-based modalities.
It
appears that the advantages of email marital therapy will promote further
development of this modality. Email therapy may be useful for couples that
would otherwise never seek any type of therapy.
It may also be useful as an alternative to talk therapy when either
modality could be appropriate. We also conclude based on the experience with
four out of eleven couples in our study that email therapy can facilitate
transition to conventional, office-based, therapy when the latter modality
is more suited to clients' needs. In short, the advantages of marital
therapy on the Internet are too obvious to ignore.
Based
on this study we strongly recommend further research on this type of
counseling modality with couples. Further research is necessary to develop
specific procedures and ethical guidelines for varying constellations of
clients: individual, couples, and families. For example, the conclusions we
draw here apply only to married couples. We do not know from studying
couples whether or not our experience could serve us in counseling
individuals or families. We assume that on the Internet specialized
experience is required for each constellation of clients.
Other
questions still await research findings. Can counselors who believe that
face-to-face interaction with clients is essential serve as online
counselors? We also do not know
how the clients perceive the medium and how they think it should be used.
Finally, we had four couples out of eleven who opted out of this
process informing us that they prefer face-to-face counseling. It would be
interesting to know why they chose not to participate. In short, while we
await findings from further research, marital therapists can proceed
cautiously to provide marital therapy on the Internet for carefully screened
couples.
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