- Email: [email protected]
Couples group therapy conducted via computer-mediated communication: A preliminary case study
Pergamon
Computers in Human Behavior, Vol. 12, No. 2, pp. 301-312, 1996 Copyright © 1996 ElsevierScience Ltd Printed in Great Britain. All fights reserved 0747-5632/96 $15.00 + 0.00
S0747-5632(96)00009-X
Couples Group Therapy Conducted via Computer-Mediated Communication: A Preliminary Case Study
Fred M. Sander Mt. Sinai School of Medicine New York
Abstract - - This report will describe an experiment in shifting a couples group from sessions held in my office (or "in-real-life' as computer users might say) to sessions conducted from our homes using personal computers. I will place this experiment in context, describe some of the process (including what may be the first reported 'Freudian slip" in cyberspace), and then mention some limitations and potentialities of group therapy conducted via computer-mediated communication. Copyright © 1996 Elsevier Science Ltd
Curing the sick is not enough; one must cure them with methods accepted by the community. (Ellenberger, 1970, p. 57) When the union of the born and the made is complete, our fabrications will learn, adapt, heal themselves, and evolve. (Kelly, 1994, p .4)
Requests for reprints should be addressed to Fred M. Sander, M.D., 200 East 89th Street, Suite 10G, N e w York, N Y 10128.
301
302
Sander
CONTEXT I am a psychoanalyst and family therapist who has been conducting longterm couples group therapy for the past 10 years. In July 1993, I purchased a laptop computer and joined Compuserve, one of the larger computer networks that provide a host of services. Through its many forums, subscribers can communicate with others who share similar interests. People post announcements, opinions, personal reviews, and, often within minutes, get responses about all kinds of issues. This type of communication often leads to lively and interesting exchanges which one can join in or just listen in on. Most relevant to this experiment, the network affords an opportunity for strangers anywhere in the world, with a telephone line, computer, and appropriate software, to 'meet' and 'chat' with each other. I originally joined because a psychoanalytic bulletin board sponsored by the Chicago Psychoanalytic Institute was available. On this bulletin board, discussions of Lacan or chaos theory alternated with practical matters such as how to get the best software for billing purposes, how psychoanalytic institutes can best deal with the denial of illness in elderly colleagues, and suggestions on course curricula. By November, I was 'hooked' on the computer, and started to catch up with a technology that was, with its rapidly evolving electronic interactive possibilities, making the 21st century closer than it already is. Around this time, while vacationing with friends in the Caribbean, we found ourselves late one night using a Compuserve service called CB Simulator and participating in computer-mediated conversations with people around the world. In keeping with the usual ambivalence about anything new, some of us were unimpressed with what seemed like frivolous 'talk', while others were impressed with this further shrinking of our world into a global village. During these random conversations with people in other countries, I noticed that the Compuserve software allowed one to engage in 'private' conversations with another person or, relevant to the current experiment, to 'form a private group' by 'inviting' people into a 'closed' group. Although most communication in CB Simulator is open to and can be 'monitored' by anyone, the formation of a private group gives the participants a metaphoric 'room of their own'. As I familiarized myself with Compuserve, the media, almost daily, were carrying articles about how computers allowed large numbers of people to meet, narrate stories, help or annoy each other, marry, and even mourn the loss of one of their fellow 'cyberspacers' (Katz, 1994; Lewis, 1994). A review of the social psychology of computer conferencing is beyond the scope of the current contribution.
Couples group therapy
303
I am not sure when I first thought that a couples group I was working with might meet via computer, but it may have been when one couple was unable to attend because of baby-sitting conflicts. I did not know if anyone had run a couples group, or any group, in this way before. I recalled from the early days of my psychiatric training, some 30 years ago, that there were already attempts to explore computer-assisted therapy (Colby, Watt, & Gilbert, 1966). A literature search combining computers and therapy (using Silver Platter 3.11) revealed over 80 references increasing in frequency over the past 20 years. There were no citations specifically dealing with computer-assisted group therapy. Some of the references included a number of applications from data storage, initial assessment of patients, teaching psychotherapy, simulation of patients and therapists, and evaluation of treatments. Some indicated the potential for, and inevitable use of, computer-assisted therapy (Karasu, 1992). There were a number of reports of computer-assisted cognitive and behavioral therapies. Some included discussions of topics such as the resistances to the use of this technology as well as the ethics involved. Colby, Gould, and Aronson (1989) recently described a method of short-term computer-assisted psychotherapy for stress-related conditions and then replied to a number of objections voiced by professional colleagues. They also cited thorough reviews of computer-assisted psychotherapy by Lawrence (1986) and Sampson (1986). The journal Family Therapy had an issue devoted to the topic in 1986. The ethical and professional issues associated with computer-assisted therapy have been discussed by Ford (1993), who included early attempts by the American Psychological Association to develop guidelines. Some software now provides therapy without a human therapist involved. Can this be considered 'therapy'? Is computer-assisted therapy conducted across state borders a violation of licensure rules? Such questions will have to be addressed as computer-assisted therapy continues to expand. The three therapy groups I run consist of three or four couples and are not time-limited in terms of numbers of sessions. Generally, the couples do not end as a group. However, in one group, two couples, feeling comfortable with the progress they had made, were ready to terminate at the end of 1993. A third couple, relatively new to the group, was having difficulty continuing because of financial constraints. When I realized that all the couples had some familiarity with computers, I proposed that, after our December termination, we might try three additional sessions using our computers. Because of its experimental nature, I did not charge for these sessions. Each couple readily agreed and we planned for three Sunday evening sessions in January. It turned out that the third couple's computer was not able to install Compuserve, so the sessions included the two couples ready to terminate. We
304
Sander
planned one final postexperiment debriefing session in my office. All three couples attended. To my surprise, it turned out that the software also made the recording of the sessions possible and I sent the couples transcripts of the last computer session. The husband in the third couple, a journalist, was interested to see how a transcript captured the verbal accuracy of a meeting. For the most part, the group felt the sessions paled compared with the inperson ones. Although socializing was discouraged while working together as a group, the three couples went out to dinner after that final session. This may have marked the end of the 'rule of abstinence' as well as a reaction to the 'dehumanized' feel of the computer meetings.
BRIEF DESCRIPTION OF THE COUPLES AND THE TECHNOLOGY Pat and Rob, now in their mid-forties, first came to see me in their midthirties in conflict over whether to go ahead with an imminent adoption. They feared their marriage was not strong enough to include children and they began therapy with a separation. After a couple of years of therapy, with the adoption of their first child and improvement in their relationship, they stopped prematurely for financial reasons. They returned after the adoption of a second child led to their marriage becoming, according to Rob, 'comatose'. I put them into a group I was starting in 1991 and in which they have usually taken leadership roles. Their children are now 9 and 4 years old and their marriage is generally more gratifying. Gil and Jil, 64 and 47, respectively, came because Jil felt Gil was tuned out most of the time. Indeed, he occasionally dozed off in the group sessions. Their 13-year-old son's school performance was a source of concern to them. I put them in the couples group after about a year of conjoint therapy. The marital relationship improved as well as the son's academic work and, at the time of termination, he was applying to colleges. To begin our computer sessions, each couple logged onto Compuserve and chose CB Simulator, one of many forums in the Compuserve network in which to meet. Their names or nicknames (called 'handles') then appeared on a list called 'who's here'. The couples used abbreviations of their names that I have changed for reasons of confidentiality to 'Patrob' and 'Giljil'. My handle was 'newuse', reflecting this new way of conducting couples group therapy. While first experimenting as a newcomer and chatting with strangers, I was challenged by a person calling himself 'Hernenway' who said: Hcmenway:
I suggest you change your name
soon.
Couples group therapy Newuse:
why?
Hemenway:
newuse won't get much respect!
Newuse:
OK, I may change to oldtimer or dangerfield.
Hemenway:
Much better
305
This excerpt illustrates how an exchange appears on the computer screen. As we became further acquainted, I discovered he was a 15-year-old boy living in Baltimore, he hoped to be a writer and was preoccupied with getting his driver's license. When he learned I was a psychiatrist, he asked what my impressions of him were. I told him I sensed he was an adventurer and before we logged off, as an amateur Tevya, the matchmaker in Fiddler on the Roof, I told him of another adventuresome teenager I had 'met' while on the Drama section of the Showbiz forum on Compuserve. I include this aside to underscore that, just as in real life, one is at the boundary of a world of others on the way to and from the group. On one occasion, I encountered a press conference conducted online by Vice President Gore. How involved one gets in this potential cyberspace is, of course, an individual matter (cf. Life on the Screen by Turkle, 1995). It is important to know that to form a 'private group' anyone listed in the 'who's here' column can invite anyone else listed to form such a group. So when the 'handles' Patrob and Giljil appeared in the 'who's here' list I asked them if they wanted to join a group discussion. Once in a private group, however, one's name remains on the 'who's here' list and one can then be interrupted by a stranger trying, as Hemenway did, to 'talk'. At first, such intrusions led some to feel the boundaries of the group could be broken and confidentiality lost. This is not so. The privacy of the group remains, although an outsider may try to make contact with a group member. Before starting the sessions properly, I made 5 - 1 0 min trial runs with each couple. In the first contact with Patrob, Rob immediately noted the slower nature of the communication, a limitation I will touch on later. Long before the couples therapy, he had been in a psychoanalysis of moderate length and I reminded him that therapy is not all that 'efficient'! However, Rob also remarked that it cut out travel time, no small matter for him and Pat who spent an hour commuting each way to my office. There was a brief exchange about ways to express nonverbal signs, such as 'giggle' < g > . We acknowledged that we might have to learn different symbols, signifying nonverbal cues, if we were communicating regularly on the computer. I was aware that a younger generation, raised with computers, more computer literate and fluent than most of us over 40 years old, would take to this communication much more easily.
306
Sander
We also corrected a potential problem in the trial run. Since each couple has only one keyboard, each member of the couple would have to signify which one of them was 'talking' by typing in his/her first initial before each posting. In addition, during our trial run, Rob was concerned with his 'typos' which I reminded him reflected his familiar trait of perfectionism. Pat sarcastically added "nothing new", it being a trait of his that she dislikes. I suggested they might air this when we started the group the following day, if they wished.
TRANSCRIPT OF FREUDIAN SLIP I will now turn to the segment of the third session just as it appeared on the computer screen. Along with the typos and grammatical lapses, it contains a Freudian slip that I discovered while later studying the transcript. Gil and Jil had been late in logging on and I had to call them by phone, on a separate line, to ask where they were. After they joined the group, there was some questioning of their resistance that was probably related to the ending of the group as well as to the frustrations during the two previous 1-hr computer sessions. (In parentheses and italics are comments of mine to help orient the reader.) patrob
IP:
listen folks, i would never bother with this if i h a d n ' t met all of you in p e r s o n . . , when i'm typing i see your f a c e s . . , that's all that keeps me talking or interested in what's being said . . . maybe this is a t y p e . . , i can't relate unless i hear a voice, watch a face, note e x p r e s s i o n s . . , words just d o n ' t do it unless like a novel the character is already built.
newuse
I
ditto
(I felt here like mirroring Pat and, I believe, the group's frustration.) giljil
Ig:
rob how's u arm
(An example of the group's general level of support and concern for one another as, in the previous session, Rob had reported injuring his arm in a fall.) patrob
IP:
so there's a limit to how much can be sent at once.
(This refers to a previous comment about each couple's different software which allowed them to send either one line or a complete paragraph at one time.) giljil
Ig:
we all have colds
patrob
JR:
I saw the orthopedist today.
(replying to Gil'S question about his arm)
Couples group therapy
307
He said that I had broken my dorsal radial cortex. Three more weeks in the brace.
(The next segment included a 'confession' to me regarding the group's breaking a rule of not socializing during the course of the group therapy, by having planned dinner after our upcoming review session. Then, after mention of Gil and Jil's son's college applications, the session continued as follows.) patrob
IR:
We went to see The Sisters Rosensweig
(a Broadway play about a reunion of three sisters) on Saturday night. It was interesting but somewhat disappointing. It reminded me a little bit of this cybergroup[ giljil
Ig
i went in a racewalk this past sat and re injured my f o o t . . , my podiatrist said i getting ole and just won't face it i really get depressed at this prospect and react by figuring out someway to prepare myself for recovery.
(The past two comments were probably typed simultaneously. They are clearly unrela~d rather than reflecting a change of subject or a manifestation of not listening to one another. The current technology and format increases the likelihood of such unrelated postings.) patrob
IP
maybe you just have to talk to a race walker e x p e r t . . , a PT who believes in e x e r c i s e . . .
(A supportive comment from Pat to Gil. I chose at this moment to pick up on the previous allusion to the play, with which I was familiar.) newuse
I
This cybergp is not as funny as sisters rosen but I believe h e a l t h i e r . . , none of them
(in the play) sustained a relationship as I remember it patrob
[p
what about Gorgeous?
giljil
Ig
who was gorgeous?
newuse
I
never saw her husband, in sisters
patrob
Ip
in the Sisters R. the middle sister is 'Dr.' G e o r g e o u s . . . a radio talk show healer of h e a r t s . . , and heads
I
comes close to describing me[
newuse
(Again, I was picking up on Rob's earlier comparison of the play and the group.) giljil
[j what an e g o . . , its disgusting (.4 direct and, I believe, playful expression of anger at me.)
patrob
[p
oh jil its like saying a sloppy joe is like beef b o u r g i g n o n . . , to say fred is like dr. g . . .
308
Sander
IP newuse
I
i mean fred is the real thing.., the bourgignon !!!!!(Not sure what I was being compared to) so much better to
digest? (In retrospect, it seems there was anger at me for feeding them computer therapy= sloppy joe vs. the in-office 'real thing'. PAT'S SLIP, BEFORE S H E CORRECTED IT, F I R S T ASSOCIATED M E W I T H S L O P P Y JOES R A T H E R T H A N BEEF BOURGIGNON.)
giljil
[j
my apple pie is done, slow oven
Ig
yesterday's edition had the crust of the century
patrob
LP
giljil
Ig
i was talking about yesterday's apple pie
patrob
IP
sounds super
(The group continues to associate to food, and, perhaps, to their increased feelings of competence upon termination/graduation to feed themselves...)
giljil
Ig
we are frantically baking for our soon to be departed son
( . . . and deal with separations.)
DISCUSSION OF TRANSCRIPT This brief segment f r o m a c o m p u t e r - m e d i a t e d group therapy session illustrates several points. Despite formidable, but probably correctable, obstacles it shows the possibility of this form of therapeutic intervention. The slowness, fragmentation, and resistance can be attributed to (a) aspects of the technology and (b) the resentment over a second termination while experimenting with a frustrating m e d i u m that was new to all o f us. N o n e the less, one could imagine, with the rapidly evolving changes in the technology itself and with experience, greater facility with the technology. I, for example, was still too focused on mastering the technology itself to m a k e the following observations. I might have interpreted the anger at me for putting t h e m t h r o u g h the experiment (expressed in arriving late, in the Freudian slip, and m o r e directly in Jil's comment, " w h a t an ego . . . it's disgusting"). The slip associated me and the process with bad, 'sloppy' feeding. Meanwhile, the group acted u p o n its frustration with the process, as well as the termination, by planning an unprecedented dinner together. Also manifest, at this time, was this group's feeling of competence in taking care of themselves, baking pies for their soon to be graduated son, a graduation paralleling the group's graduation from therapy a n d giving up their
Couples group therapy
309
dependence upon me and each other. Jil, who had baked "the crust of the century", had in the past year made several advances in her career as an artist by getting her work seen and sold. Certainly, such interpretations could be made via computer-mediated communication as they are for in-person sessions, once a group is more accustomed to the technology.
LIMITATIONS AND POTENTIALITIES This early experiment in using computer-mediated communication to run a couples group was largely characterized by a certain clumsiness and disjointedness. Part of this is attributable to our inexperience with the technology and part is due to the technology itself. In the current experiment, the online real-time quality was also cumbersome, in that everyone had to wait while one group member at a time typed out his/her communication. Typing simultaneously, which also occurred, often led to fragmented and unrelated communication. These obstacles would have been even more difficult if all three couples were online. However, it is only a matter of time before visual and auditory inputs, already present, for example, in network television conferencing, are generally available. Then the lack of immediacy of the interaction that Pat bemoaned could be corrected. I think this group knew each other well enough to overcome some of the missing cues they were used to. Whether such groups could 'meet' in cyberspace without prior experience with one another remains to be seen. A personal communication from an analytically oriented therapist who conducted a 6-month time-limited group therapy in 1990, on a New York-based computer network called ECHO, reported reasonable initial success. She emphasized, contrary to the limitation noted earlier, that in her group which had never met one another, the anonymity and absence of nonverbal communication facilitated personal revelations and the rapid development of transference feelings (J. Caggiano, May 1994, personal communication). Other colleagues familiar with computer 'chatting' have noted the rapid development of spontaneous personal revelations attributable to the anonymity afforded by the technology. The tendency to reveal oneself more readily to computers has been demonstrated in a number of studies cited by Plutchik and Karasu (1990, 1991). Although Dr. Caggiano's group on ECHO met primarily in asynchronous time, she also had individual online sessions with members of the group. While my group met exclusively in synchronous time for the three sessions, hers met occasionally that way. Asynchronous time conferences means that each participant can log on any time and post a question, problem, or response to earlier postings by
310
Sander
others in the group. Such asynchronous communication might limit 'process' to a degree but would offset the distortions caused by waiting for others to type their comments or by experiencing fragmented communications. Asynchronous conferring eliminates these obstacles and is more time efficient. This could also be achieved by ordinary e-mail sent privately between all the participants. One could also overcome the simultaneous and fragmented communications by asking the couples to post their communications in some ordered sequence. Such structuring, which encourages rational over emotional interactions, a technique in Bowenian couples group therapy (Bowen, 1978), would, I believe, be a slow and inefficient process limiting spontaneity. Asynchronous communication would be more efficient in that each person could intermittently log onto a private bulletin board, or by e-mail, every day or every few days as schedules permit. The therapist leader would participate, at some agreed-upon intervals, note resistances, and interpret more latent material where appropriate. Asynchronous conferences or bulletin boards work quite well in those community-based computer networks that provide advice and general support to people. For example, I learned of a recently published book, The Virtual Community by Howard Rheingold (1993), which describes an electronically connected 'community' based in San Francisco, called 'The Well'. Rheingold described The Well as a virtual village that grew from a few hundred people in 1985 to 8,000 by 1993. He noted that many of these people use the virtual community as a form of psychotherapy. He cites Oldenburg (1991), who proposed that there are three essential places in people's lives: the place we live, the place we work, and the place we gather for conviviality. The loss of cafrs, beauty shops, pubs, and town squares, he argued, has torn the social fabric of community life. Rheingold's book is a very compelling description of how The Well may be repairing that isolation for many people, thereby creating a 'virtual' therapeutic community. Within a specifically therapeutic framework, interpretation might supplement the support and reality testing of such group exchanges. Such an asynchronous format, perhaps combined with real-time sessions, deserve exploration. The possibility of reaching people in more remote areas who have no access to therapy is an obvious potential application of this technology. Moreover, the smallness of some communities precludes anonymity and makes such computer-mediated therapy another potential use for persons in remote areas. The housebound elderly or the disabled could especially be reached in this way. This media clearly has the potential to reach a large number of client patients in a cost-effective way. Diagnosis and medical treatment plans, resulting from the transmission of ECGs, X-rays, and other lab results, are already in use for persons living far from medical centers.
Couples group therapy
311
CONCLUSION This preliminary communication describes the feasibility of computermediated couples group therapy. It is, I believe, the first published description of such an effort. The inevitable development of further sophisticated technology will make some form of computer-mediated individual, family, and group therapy almost a certainty. Whether it will enhance communication and therapeutic possibilities or further dehumanize communication depends, of course, upon the refinement and evaluation of our efforts and findings. Rheingold (1993) asks this question in a broader context. He asks whether • . . cyberspace is an informal public place where people can rebuild the aspects of the community that were lost when the malt shop became a mall. Or perhaps it is precisely the wrong place to look for the rebirth of community, offering not a tool for conviviality, but a life denying simulacrum of real passion and true commitment to one another. In either case we need to find out soon. (p. 26)
This communication is presented in that spirit of exploration that has been a part of the evolution of our mental health sciences.
REFERENCES Bowen, M. (1978)• Family therapy in clinical practice. Northvale, NJ: Jason Aronson. Colby, K. M., Gould, R. L., & Aronson, G. (1989). Pros and cons of computer-assisted psychotherapy• Journal of Nervous and Mental Disorders, 177, 105-108. Colby, K. M., Watt, J. B., & Gilbert, J. P. (1966)• A computer method of psychotherapy: Preliminary communication. Journal of Nervous and Mental Disorders, 142, 148-152• Ellenberger, H. (1970)• The discovery of the unconscious. New York: Basic Books. Ford, B. D. (1993)• Ethical and professional issues in computer assisted therapy. Computers in Human Behavior, 9, 387-400• Karasu, B. (1992)• The worst of times, the best of times: Psychotherapy in the 1990s. Journal of Psychotherapy w Practice and Research, 1, 2-15. Katz, J. (1994, January 23). The tales they tell in cyber-space are a whole other story. New York Times, Arts and Leisure Section, pp. 1, 30. Kelly, K. (1994)• Out of control: The rise of neo-biological civilization. New York: Addison Wesley. Lawrence, G. (1986). Using computers for the treatment of psychological problems. Computers in Human Behavior, 4, 43-62• Lewis, P. H. (1994, March 8). Strangers, not their computers, build a network in time of grief. New York Times, p. 1. Oldenburg, R. (1991). The great good place: Cafes, coffee shops, community centers, beauty parlors, general stores, bars, hangouts, and how they get through the day. New York: Paragon House. Plutchik, R., & Karasu, B. (1990). Computers in interviewing and psychotherapy. In D. Baskin (Ed.), Computer applications in psychiatry and psychology• New York: Brunner/ Mazel.
312
Sander
Plutchik, R., & Karasu, B. (1991). Computers in psychotherapy: An overview. Computers in Human Behavior, 7, 33-44. Rheingold, H. (1993). The virtual community. Addison Wesley. Sampson, J. (1986). The use of computer-assisted instruction in support of psychotherapeutic processes. Computers in Human Behavior, 4, 1-19. Turkle, S. (1995). Life on the screen: Identity in the age of the internet. Simon & Schuster.
Computers in Human Behavior, Vol. 12, No. 2, pp. 301-312, 1996 Copyright © 1996 ElsevierScience Ltd Printed in Great Britain. All fights reserved 0747-5632/96 $15.00 + 0.00
S0747-5632(96)00009-X
Couples Group Therapy Conducted via Computer-Mediated Communication: A Preliminary Case Study
Fred M. Sander Mt. Sinai School of Medicine New York
Abstract - - This report will describe an experiment in shifting a couples group from sessions held in my office (or "in-real-life' as computer users might say) to sessions conducted from our homes using personal computers. I will place this experiment in context, describe some of the process (including what may be the first reported 'Freudian slip" in cyberspace), and then mention some limitations and potentialities of group therapy conducted via computer-mediated communication. Copyright © 1996 Elsevier Science Ltd
Curing the sick is not enough; one must cure them with methods accepted by the community. (Ellenberger, 1970, p. 57) When the union of the born and the made is complete, our fabrications will learn, adapt, heal themselves, and evolve. (Kelly, 1994, p .4)
Requests for reprints should be addressed to Fred M. Sander, M.D., 200 East 89th Street, Suite 10G, N e w York, N Y 10128.
301
302
Sander
CONTEXT I am a psychoanalyst and family therapist who has been conducting longterm couples group therapy for the past 10 years. In July 1993, I purchased a laptop computer and joined Compuserve, one of the larger computer networks that provide a host of services. Through its many forums, subscribers can communicate with others who share similar interests. People post announcements, opinions, personal reviews, and, often within minutes, get responses about all kinds of issues. This type of communication often leads to lively and interesting exchanges which one can join in or just listen in on. Most relevant to this experiment, the network affords an opportunity for strangers anywhere in the world, with a telephone line, computer, and appropriate software, to 'meet' and 'chat' with each other. I originally joined because a psychoanalytic bulletin board sponsored by the Chicago Psychoanalytic Institute was available. On this bulletin board, discussions of Lacan or chaos theory alternated with practical matters such as how to get the best software for billing purposes, how psychoanalytic institutes can best deal with the denial of illness in elderly colleagues, and suggestions on course curricula. By November, I was 'hooked' on the computer, and started to catch up with a technology that was, with its rapidly evolving electronic interactive possibilities, making the 21st century closer than it already is. Around this time, while vacationing with friends in the Caribbean, we found ourselves late one night using a Compuserve service called CB Simulator and participating in computer-mediated conversations with people around the world. In keeping with the usual ambivalence about anything new, some of us were unimpressed with what seemed like frivolous 'talk', while others were impressed with this further shrinking of our world into a global village. During these random conversations with people in other countries, I noticed that the Compuserve software allowed one to engage in 'private' conversations with another person or, relevant to the current experiment, to 'form a private group' by 'inviting' people into a 'closed' group. Although most communication in CB Simulator is open to and can be 'monitored' by anyone, the formation of a private group gives the participants a metaphoric 'room of their own'. As I familiarized myself with Compuserve, the media, almost daily, were carrying articles about how computers allowed large numbers of people to meet, narrate stories, help or annoy each other, marry, and even mourn the loss of one of their fellow 'cyberspacers' (Katz, 1994; Lewis, 1994). A review of the social psychology of computer conferencing is beyond the scope of the current contribution.
Couples group therapy
303
I am not sure when I first thought that a couples group I was working with might meet via computer, but it may have been when one couple was unable to attend because of baby-sitting conflicts. I did not know if anyone had run a couples group, or any group, in this way before. I recalled from the early days of my psychiatric training, some 30 years ago, that there were already attempts to explore computer-assisted therapy (Colby, Watt, & Gilbert, 1966). A literature search combining computers and therapy (using Silver Platter 3.11) revealed over 80 references increasing in frequency over the past 20 years. There were no citations specifically dealing with computer-assisted group therapy. Some of the references included a number of applications from data storage, initial assessment of patients, teaching psychotherapy, simulation of patients and therapists, and evaluation of treatments. Some indicated the potential for, and inevitable use of, computer-assisted therapy (Karasu, 1992). There were a number of reports of computer-assisted cognitive and behavioral therapies. Some included discussions of topics such as the resistances to the use of this technology as well as the ethics involved. Colby, Gould, and Aronson (1989) recently described a method of short-term computer-assisted psychotherapy for stress-related conditions and then replied to a number of objections voiced by professional colleagues. They also cited thorough reviews of computer-assisted psychotherapy by Lawrence (1986) and Sampson (1986). The journal Family Therapy had an issue devoted to the topic in 1986. The ethical and professional issues associated with computer-assisted therapy have been discussed by Ford (1993), who included early attempts by the American Psychological Association to develop guidelines. Some software now provides therapy without a human therapist involved. Can this be considered 'therapy'? Is computer-assisted therapy conducted across state borders a violation of licensure rules? Such questions will have to be addressed as computer-assisted therapy continues to expand. The three therapy groups I run consist of three or four couples and are not time-limited in terms of numbers of sessions. Generally, the couples do not end as a group. However, in one group, two couples, feeling comfortable with the progress they had made, were ready to terminate at the end of 1993. A third couple, relatively new to the group, was having difficulty continuing because of financial constraints. When I realized that all the couples had some familiarity with computers, I proposed that, after our December termination, we might try three additional sessions using our computers. Because of its experimental nature, I did not charge for these sessions. Each couple readily agreed and we planned for three Sunday evening sessions in January. It turned out that the third couple's computer was not able to install Compuserve, so the sessions included the two couples ready to terminate. We
304
Sander
planned one final postexperiment debriefing session in my office. All three couples attended. To my surprise, it turned out that the software also made the recording of the sessions possible and I sent the couples transcripts of the last computer session. The husband in the third couple, a journalist, was interested to see how a transcript captured the verbal accuracy of a meeting. For the most part, the group felt the sessions paled compared with the inperson ones. Although socializing was discouraged while working together as a group, the three couples went out to dinner after that final session. This may have marked the end of the 'rule of abstinence' as well as a reaction to the 'dehumanized' feel of the computer meetings.
BRIEF DESCRIPTION OF THE COUPLES AND THE TECHNOLOGY Pat and Rob, now in their mid-forties, first came to see me in their midthirties in conflict over whether to go ahead with an imminent adoption. They feared their marriage was not strong enough to include children and they began therapy with a separation. After a couple of years of therapy, with the adoption of their first child and improvement in their relationship, they stopped prematurely for financial reasons. They returned after the adoption of a second child led to their marriage becoming, according to Rob, 'comatose'. I put them into a group I was starting in 1991 and in which they have usually taken leadership roles. Their children are now 9 and 4 years old and their marriage is generally more gratifying. Gil and Jil, 64 and 47, respectively, came because Jil felt Gil was tuned out most of the time. Indeed, he occasionally dozed off in the group sessions. Their 13-year-old son's school performance was a source of concern to them. I put them in the couples group after about a year of conjoint therapy. The marital relationship improved as well as the son's academic work and, at the time of termination, he was applying to colleges. To begin our computer sessions, each couple logged onto Compuserve and chose CB Simulator, one of many forums in the Compuserve network in which to meet. Their names or nicknames (called 'handles') then appeared on a list called 'who's here'. The couples used abbreviations of their names that I have changed for reasons of confidentiality to 'Patrob' and 'Giljil'. My handle was 'newuse', reflecting this new way of conducting couples group therapy. While first experimenting as a newcomer and chatting with strangers, I was challenged by a person calling himself 'Hernenway' who said: Hcmenway:
I suggest you change your name
soon.
Couples group therapy Newuse:
why?
Hemenway:
newuse won't get much respect!
Newuse:
OK, I may change to oldtimer or dangerfield.
Hemenway:
Much better
305
This excerpt illustrates how an exchange appears on the computer screen. As we became further acquainted, I discovered he was a 15-year-old boy living in Baltimore, he hoped to be a writer and was preoccupied with getting his driver's license. When he learned I was a psychiatrist, he asked what my impressions of him were. I told him I sensed he was an adventurer and before we logged off, as an amateur Tevya, the matchmaker in Fiddler on the Roof, I told him of another adventuresome teenager I had 'met' while on the Drama section of the Showbiz forum on Compuserve. I include this aside to underscore that, just as in real life, one is at the boundary of a world of others on the way to and from the group. On one occasion, I encountered a press conference conducted online by Vice President Gore. How involved one gets in this potential cyberspace is, of course, an individual matter (cf. Life on the Screen by Turkle, 1995). It is important to know that to form a 'private group' anyone listed in the 'who's here' column can invite anyone else listed to form such a group. So when the 'handles' Patrob and Giljil appeared in the 'who's here' list I asked them if they wanted to join a group discussion. Once in a private group, however, one's name remains on the 'who's here' list and one can then be interrupted by a stranger trying, as Hemenway did, to 'talk'. At first, such intrusions led some to feel the boundaries of the group could be broken and confidentiality lost. This is not so. The privacy of the group remains, although an outsider may try to make contact with a group member. Before starting the sessions properly, I made 5 - 1 0 min trial runs with each couple. In the first contact with Patrob, Rob immediately noted the slower nature of the communication, a limitation I will touch on later. Long before the couples therapy, he had been in a psychoanalysis of moderate length and I reminded him that therapy is not all that 'efficient'! However, Rob also remarked that it cut out travel time, no small matter for him and Pat who spent an hour commuting each way to my office. There was a brief exchange about ways to express nonverbal signs, such as 'giggle' < g > . We acknowledged that we might have to learn different symbols, signifying nonverbal cues, if we were communicating regularly on the computer. I was aware that a younger generation, raised with computers, more computer literate and fluent than most of us over 40 years old, would take to this communication much more easily.
306
Sander
We also corrected a potential problem in the trial run. Since each couple has only one keyboard, each member of the couple would have to signify which one of them was 'talking' by typing in his/her first initial before each posting. In addition, during our trial run, Rob was concerned with his 'typos' which I reminded him reflected his familiar trait of perfectionism. Pat sarcastically added "nothing new", it being a trait of his that she dislikes. I suggested they might air this when we started the group the following day, if they wished.
TRANSCRIPT OF FREUDIAN SLIP I will now turn to the segment of the third session just as it appeared on the computer screen. Along with the typos and grammatical lapses, it contains a Freudian slip that I discovered while later studying the transcript. Gil and Jil had been late in logging on and I had to call them by phone, on a separate line, to ask where they were. After they joined the group, there was some questioning of their resistance that was probably related to the ending of the group as well as to the frustrations during the two previous 1-hr computer sessions. (In parentheses and italics are comments of mine to help orient the reader.) patrob
IP:
listen folks, i would never bother with this if i h a d n ' t met all of you in p e r s o n . . , when i'm typing i see your f a c e s . . , that's all that keeps me talking or interested in what's being said . . . maybe this is a t y p e . . , i can't relate unless i hear a voice, watch a face, note e x p r e s s i o n s . . , words just d o n ' t do it unless like a novel the character is already built.
newuse
I
ditto
(I felt here like mirroring Pat and, I believe, the group's frustration.) giljil
Ig:
rob how's u arm
(An example of the group's general level of support and concern for one another as, in the previous session, Rob had reported injuring his arm in a fall.) patrob
IP:
so there's a limit to how much can be sent at once.
(This refers to a previous comment about each couple's different software which allowed them to send either one line or a complete paragraph at one time.) giljil
Ig:
we all have colds
patrob
JR:
I saw the orthopedist today.
(replying to Gil'S question about his arm)
Couples group therapy
307
He said that I had broken my dorsal radial cortex. Three more weeks in the brace.
(The next segment included a 'confession' to me regarding the group's breaking a rule of not socializing during the course of the group therapy, by having planned dinner after our upcoming review session. Then, after mention of Gil and Jil's son's college applications, the session continued as follows.) patrob
IR:
We went to see The Sisters Rosensweig
(a Broadway play about a reunion of three sisters) on Saturday night. It was interesting but somewhat disappointing. It reminded me a little bit of this cybergroup[ giljil
Ig
i went in a racewalk this past sat and re injured my f o o t . . , my podiatrist said i getting ole and just won't face it i really get depressed at this prospect and react by figuring out someway to prepare myself for recovery.
(The past two comments were probably typed simultaneously. They are clearly unrela~d rather than reflecting a change of subject or a manifestation of not listening to one another. The current technology and format increases the likelihood of such unrelated postings.) patrob
IP
maybe you just have to talk to a race walker e x p e r t . . , a PT who believes in e x e r c i s e . . .
(A supportive comment from Pat to Gil. I chose at this moment to pick up on the previous allusion to the play, with which I was familiar.) newuse
I
This cybergp is not as funny as sisters rosen but I believe h e a l t h i e r . . , none of them
(in the play) sustained a relationship as I remember it patrob
[p
what about Gorgeous?
giljil
Ig
who was gorgeous?
newuse
I
never saw her husband, in sisters
patrob
Ip
in the Sisters R. the middle sister is 'Dr.' G e o r g e o u s . . . a radio talk show healer of h e a r t s . . , and heads
I
comes close to describing me[
newuse
(Again, I was picking up on Rob's earlier comparison of the play and the group.) giljil
[j what an e g o . . , its disgusting (.4 direct and, I believe, playful expression of anger at me.)
patrob
[p
oh jil its like saying a sloppy joe is like beef b o u r g i g n o n . . , to say fred is like dr. g . . .
308
Sander
IP newuse
I
i mean fred is the real thing.., the bourgignon !!!!!(Not sure what I was being compared to) so much better to
digest? (In retrospect, it seems there was anger at me for feeding them computer therapy= sloppy joe vs. the in-office 'real thing'. PAT'S SLIP, BEFORE S H E CORRECTED IT, F I R S T ASSOCIATED M E W I T H S L O P P Y JOES R A T H E R T H A N BEEF BOURGIGNON.)
giljil
[j
my apple pie is done, slow oven
Ig
yesterday's edition had the crust of the century
patrob
LP
giljil
Ig
i was talking about yesterday's apple pie
patrob
IP
sounds super
(The group continues to associate to food, and, perhaps, to their increased feelings of competence upon termination/graduation to feed themselves...)
giljil
Ig
we are frantically baking for our soon to be departed son
( . . . and deal with separations.)
DISCUSSION OF TRANSCRIPT This brief segment f r o m a c o m p u t e r - m e d i a t e d group therapy session illustrates several points. Despite formidable, but probably correctable, obstacles it shows the possibility of this form of therapeutic intervention. The slowness, fragmentation, and resistance can be attributed to (a) aspects of the technology and (b) the resentment over a second termination while experimenting with a frustrating m e d i u m that was new to all o f us. N o n e the less, one could imagine, with the rapidly evolving changes in the technology itself and with experience, greater facility with the technology. I, for example, was still too focused on mastering the technology itself to m a k e the following observations. I might have interpreted the anger at me for putting t h e m t h r o u g h the experiment (expressed in arriving late, in the Freudian slip, and m o r e directly in Jil's comment, " w h a t an ego . . . it's disgusting"). The slip associated me and the process with bad, 'sloppy' feeding. Meanwhile, the group acted u p o n its frustration with the process, as well as the termination, by planning an unprecedented dinner together. Also manifest, at this time, was this group's feeling of competence in taking care of themselves, baking pies for their soon to be graduated son, a graduation paralleling the group's graduation from therapy a n d giving up their
Couples group therapy
309
dependence upon me and each other. Jil, who had baked "the crust of the century", had in the past year made several advances in her career as an artist by getting her work seen and sold. Certainly, such interpretations could be made via computer-mediated communication as they are for in-person sessions, once a group is more accustomed to the technology.
LIMITATIONS AND POTENTIALITIES This early experiment in using computer-mediated communication to run a couples group was largely characterized by a certain clumsiness and disjointedness. Part of this is attributable to our inexperience with the technology and part is due to the technology itself. In the current experiment, the online real-time quality was also cumbersome, in that everyone had to wait while one group member at a time typed out his/her communication. Typing simultaneously, which also occurred, often led to fragmented and unrelated communication. These obstacles would have been even more difficult if all three couples were online. However, it is only a matter of time before visual and auditory inputs, already present, for example, in network television conferencing, are generally available. Then the lack of immediacy of the interaction that Pat bemoaned could be corrected. I think this group knew each other well enough to overcome some of the missing cues they were used to. Whether such groups could 'meet' in cyberspace without prior experience with one another remains to be seen. A personal communication from an analytically oriented therapist who conducted a 6-month time-limited group therapy in 1990, on a New York-based computer network called ECHO, reported reasonable initial success. She emphasized, contrary to the limitation noted earlier, that in her group which had never met one another, the anonymity and absence of nonverbal communication facilitated personal revelations and the rapid development of transference feelings (J. Caggiano, May 1994, personal communication). Other colleagues familiar with computer 'chatting' have noted the rapid development of spontaneous personal revelations attributable to the anonymity afforded by the technology. The tendency to reveal oneself more readily to computers has been demonstrated in a number of studies cited by Plutchik and Karasu (1990, 1991). Although Dr. Caggiano's group on ECHO met primarily in asynchronous time, she also had individual online sessions with members of the group. While my group met exclusively in synchronous time for the three sessions, hers met occasionally that way. Asynchronous time conferences means that each participant can log on any time and post a question, problem, or response to earlier postings by
310
Sander
others in the group. Such asynchronous communication might limit 'process' to a degree but would offset the distortions caused by waiting for others to type their comments or by experiencing fragmented communications. Asynchronous conferring eliminates these obstacles and is more time efficient. This could also be achieved by ordinary e-mail sent privately between all the participants. One could also overcome the simultaneous and fragmented communications by asking the couples to post their communications in some ordered sequence. Such structuring, which encourages rational over emotional interactions, a technique in Bowenian couples group therapy (Bowen, 1978), would, I believe, be a slow and inefficient process limiting spontaneity. Asynchronous communication would be more efficient in that each person could intermittently log onto a private bulletin board, or by e-mail, every day or every few days as schedules permit. The therapist leader would participate, at some agreed-upon intervals, note resistances, and interpret more latent material where appropriate. Asynchronous conferences or bulletin boards work quite well in those community-based computer networks that provide advice and general support to people. For example, I learned of a recently published book, The Virtual Community by Howard Rheingold (1993), which describes an electronically connected 'community' based in San Francisco, called 'The Well'. Rheingold described The Well as a virtual village that grew from a few hundred people in 1985 to 8,000 by 1993. He noted that many of these people use the virtual community as a form of psychotherapy. He cites Oldenburg (1991), who proposed that there are three essential places in people's lives: the place we live, the place we work, and the place we gather for conviviality. The loss of cafrs, beauty shops, pubs, and town squares, he argued, has torn the social fabric of community life. Rheingold's book is a very compelling description of how The Well may be repairing that isolation for many people, thereby creating a 'virtual' therapeutic community. Within a specifically therapeutic framework, interpretation might supplement the support and reality testing of such group exchanges. Such an asynchronous format, perhaps combined with real-time sessions, deserve exploration. The possibility of reaching people in more remote areas who have no access to therapy is an obvious potential application of this technology. Moreover, the smallness of some communities precludes anonymity and makes such computer-mediated therapy another potential use for persons in remote areas. The housebound elderly or the disabled could especially be reached in this way. This media clearly has the potential to reach a large number of client patients in a cost-effective way. Diagnosis and medical treatment plans, resulting from the transmission of ECGs, X-rays, and other lab results, are already in use for persons living far from medical centers.
Couples group therapy
311
CONCLUSION This preliminary communication describes the feasibility of computermediated couples group therapy. It is, I believe, the first published description of such an effort. The inevitable development of further sophisticated technology will make some form of computer-mediated individual, family, and group therapy almost a certainty. Whether it will enhance communication and therapeutic possibilities or further dehumanize communication depends, of course, upon the refinement and evaluation of our efforts and findings. Rheingold (1993) asks this question in a broader context. He asks whether • . . cyberspace is an informal public place where people can rebuild the aspects of the community that were lost when the malt shop became a mall. Or perhaps it is precisely the wrong place to look for the rebirth of community, offering not a tool for conviviality, but a life denying simulacrum of real passion and true commitment to one another. In either case we need to find out soon. (p. 26)
This communication is presented in that spirit of exploration that has been a part of the evolution of our mental health sciences.
REFERENCES Bowen, M. (1978)• Family therapy in clinical practice. Northvale, NJ: Jason Aronson. Colby, K. M., Gould, R. L., & Aronson, G. (1989). Pros and cons of computer-assisted psychotherapy• Journal of Nervous and Mental Disorders, 177, 105-108. Colby, K. M., Watt, J. B., & Gilbert, J. P. (1966)• A computer method of psychotherapy: Preliminary communication. Journal of Nervous and Mental Disorders, 142, 148-152• Ellenberger, H. (1970)• The discovery of the unconscious. New York: Basic Books. Ford, B. D. (1993)• Ethical and professional issues in computer assisted therapy. Computers in Human Behavior, 9, 387-400• Karasu, B. (1992)• The worst of times, the best of times: Psychotherapy in the 1990s. Journal of Psychotherapy w Practice and Research, 1, 2-15. Katz, J. (1994, January 23). The tales they tell in cyber-space are a whole other story. New York Times, Arts and Leisure Section, pp. 1, 30. Kelly, K. (1994)• Out of control: The rise of neo-biological civilization. New York: Addison Wesley. Lawrence, G. (1986). Using computers for the treatment of psychological problems. Computers in Human Behavior, 4, 43-62• Lewis, P. H. (1994, March 8). Strangers, not their computers, build a network in time of grief. New York Times, p. 1. Oldenburg, R. (1991). The great good place: Cafes, coffee shops, community centers, beauty parlors, general stores, bars, hangouts, and how they get through the day. New York: Paragon House. Plutchik, R., & Karasu, B. (1990). Computers in interviewing and psychotherapy. In D. Baskin (Ed.), Computer applications in psychiatry and psychology• New York: Brunner/ Mazel.
312
Sander
Plutchik, R., & Karasu, B. (1991). Computers in psychotherapy: An overview. Computers in Human Behavior, 7, 33-44. Rheingold, H. (1993). The virtual community. Addison Wesley. Sampson, J. (1986). The use of computer-assisted instruction in support of psychotherapeutic processes. Computers in Human Behavior, 4, 1-19. Turkle, S. (1995). Life on the screen: Identity in the age of the internet. Simon & Schuster.