Editorial note: John Suler is professor of Psychology at Rider University, Lawrenceville, New Jersey.

The physiology of the life online

Q: To me, starting from physiology prevents from considering the Net as pathological, a priori. The Net has many advantages we have to take in the right consideration. I refer for the MUDs, for example: assuming one or more online identities can lead to a deepener self-knowledge and to self-fulfilment. There are some risks too. What do you think about this issue? Can you tell me one or more clinical cases you experienced?

A: As in many social situations online, people may be acting out needs and wishes by assuming online persona without any real personal growth, while perhaps hurting other people - and sometimes they may be working on important personal issues by assuming those persona, resulting in psychological growth and change.

Q: I think that cyberpsychology is an important academic theme. In Italy, in the recent past, this issue wasn't holden in due consideration and the ones who studied it were looked suspiciously and, sometimes, margined. With reference to this, I'd like to know how it is considered the study of the Net, in your socio-cultural background, in the past and nowdays and what was your experience on this matter.

A: People have been skeptical about relationships online as well as psychotherapy online. But there's absolutely no doubt that people form meaningful relationships online (colleagues, friends, lovers). The same is true about online therapy. Some people are very skeptical about this, but the evidence is very clear to me that online therapy is possible and can be quite effective. The real question is not "is it possible to do therapy online" but rather "how can therapy online be effective, with what types of problems, and with what kinds of people." Online psychotherapy is a new species of psychotherapy, in some ways similar, in some ways different than f2f therapy.

Q: Can you tell me one or more examples of co-operation and conflict in an online community you experienced?

A: This is a very complex topic - not unlike asking how people cooperate and experience conflict in the in-person world. In many respects, what happens in online communities is very similar to in-person communities. The major differences is that people communicate via TEXT, which results in partial anonymity, a lack of f2f cues, and subsequently disinhibition. That disinhibition may lead to more acting out and interpersonal conflicts than we might see in f2f communities, but perhaps also more rapid self-disclosure and acts of kindness.

Q: Do you think that the emotional manifestations are more intense than in real life? If it is so, why do you think it happens?

A: In some cases this might be true. The anonymity and lack of f2f cues tends to pull for more projections and transference reactions. There is a somewhat greater tendency in online relationships to "read" meaning into what they other person has typed. There is more of a tendency to misunderstand what people mean.

Q: Do you believe that the online relationships estabilish and break off more rapidily than the face to face ones? Why? Have you any examples of them?

A: I think this might be true. Sometimes, due to that disinhibition effect, people self-disclose very quickly and establish intimacy with others very quickly. Sometimes the relationship lasts, but sometimes the intimacy develops too rapidly and people start to feel vulnerable. So they end the relationship. For some people, that rapid intimacy somehow feels false and, paradoxically, superficial since the other person "doesn't really know me." It's very easy to click the "disconnect" button and disappear if a relationship is not going well. It's very easy NOT to reply to an email. A person can always blame one's server or the internet for "not getting" a message or "not being able to connect." It's very easy on the internet to avoid saying good-bye to someone.

The psychopathology

Q: Are there any scientific pubblications containing IAD' s clinical cases?

A: There are quite a few books and articles. Check Kimberly Young's web site "The Center for Online Addiction." Also, several articles have appeared in the journal CyberPsychology and Behavior (http://www.liebertpub.com/CPB/default1.asp). Azy Barak also has a very comprehensive list of articles about online behavior, which includes articles about IAD (http://construct.haifa.ac.il/~azy/refindx.htm)

Q: Will the IAD be inserted in the next DSM' s edition, as it already seemed possible in 1993?

A: Probably not. Much more research is needed to establish IAD as a reliable and valid diagnostic category. Most researchers think that the internet facilitates or accelerates addictive behaviors that are already present in a person, rather than it creating a unique disorder.

Q: What are the most frequently associated psychopathology associated with the IAD, if there are? What are the Internet' s chatacteristics that are able to lead to psychopathology? Which are the characteristics of the subjects' personality at risk?

A: These are important and very complex questions. My article about internet addiction addresses these issues (http://www.rider.edu/users/suler/psycyber/getneed.html), and the references I mention above also explore these questions.

Q: There isn't common agreement upon the existence of Internet Addiction Disorder end its diagnostic criteria: what's your opinion on this matter?

A: I think many researchers are thinking more in terms of internet "facilitated" disorders - in other words, being online tends to accelerate or exaggerate some addictive or compulsive tendency that already is present. It's unlikely that the internet will create some serious problem in a person for whom there wasn't any preexisting weakness or vulnerability.

Q: Do you know any clinical cases of IAD? Can you tell me one of the most representative clinical cases you know, focusing on the patient's history and socio-cultural background?

A: It's interesting that although I have spoken to many people via email, chat, phone, and f2f about their lives in cyberspace, I have never come across a truly pathological internet addict - not like those that are portrayed in the media. I have received email from parents and friends of people who seemed to seriously addicted, but never "met" them myself. On the other hand, I have spoken with many people who have gone through a phase of very heavy internet use, which then tapered off as the person became adapted to life online.

Q: In your opinion, are more frequent the IAD's cases or a pathological Internet use resulting from an associated psychopathology?

A: As I mentioned, there are probably other underlying addictive tendencies that existed prior to internet use. It's possible that some people with borderline disorders or social phobias may become "addicted" to the internet.

Q: In your article "To get what you need", you state that a symptom of the pathology is the dissociation between online and offline living: to you, what are the causes of this situation?

A: When people dissociate their online life from their offline life, the online life becomes a tightly encapsulated, secret "world" that tends to swallow the person. It heightens projections and transference reactions, with little opportunity for the person to reality test by speaking with people who are not part of that secret world. All sorts of powerful needs, wishes, and fantasies become channeled into that world, so that gradually the person's psychological space becomes reduced to that online environment. The "real" world starts to lose meaning and purpose.

Q: According to the statement that there isn't a common agreement on the diagnostic criteria of the IAD, in your opinion, which are the clinical symptoms of the IAD, besides the dissociation between the online and offline living?

A: For me, the most important indicators are a decline in level of functioning in the face to face world - work, relationships with family and friends, other hobbies, even one's health and hygiene habits, tend to decay.

Q: Which are the most effective therapies?

A: It depends on the person. Behavioral interventions will work well with some. For others, a combination of behavioral interventions with cognitive and/or psychodynamic therapy will be a powerful combination. Group therapy and self-help groups might also be effective (it raises the interesting question of whether online group therapy and self-help groups can be effective in helping internet-facilitated disorders!)

The online psychotherapy

Q: Which are the ethical standards for an online psychotherapy? Do you think that the ones estabilished by the APA are sufficient?

A: Several organizations have proposed standards:

http://www.ismho.org/suggestions.html

http://www.counseling.org/gc/cybertx.htm

http://www.ihealthcoalition.org/ethics/draftcode.html

http://www.nbcc.org/ethics/wcstandards.htm

http://www.hon.ch/HONcode/Conduct.html

http://www.apa.org/ethics/stmnt01.html

Q: Which are the necessary changing of the setting for an online psychotherapy? And which are the consequences on the therapeutic process?

A: This also is a very complex issue. The most important factors involve the dynamics of text communication, anonymity, the lack of face-to-face cues, and synchronous versus asynchronous communication. Your readers might be interested in this article where I explore these issues: http://www.rider.edu/users/suler/psycyber/therapy.html

Q: In an online psychotherapy, do you think that it is possible to estabilish a therapeutic relationship? If so, which are the differences with the relationship in a traditional psychotherapy?

A: Without a doubt, a therapeutic relationship is possible. The most important differences involves those factors I mention above: the dynamics of text communication, anonymity, the lack of face-to-face cues, and synchronous versus asynchronous communication. Although this article is not about psychotherapy, it does explore the fascinating differences between in-person and online relationships:

http://www.rider.edu/users/suler/psycyber/showdown.html

Q: Which are the pathologies that are curable and not with an online psychotherapy?

A: No one knows for sure yet. Online clinical work is a good choice as a way to begin working with various types of social anxieties. As a general rule of thumb, online therapy is probably not appropriate for severe psychopathology, although more research is needed to determine this.

Q: A psychopathology involves relationship's troubles in client's life. Are there any disadvantages in an online psychotherapy to treat these clients?

A: The online therapist probably would deal with these relationship issues in much the same way as the face to face therapist. Also, some online clinicians are doing couples and marital therapy via email and chat, which seems to work well. Another interesting approach is to encourage clients to experiment with online relationships as a way to try out new ways of relating to others, and then apply that knowledge to their in-person relationships. The online relationship can be a kind of "stepping stone".

Q: According to you,which are the characteristics of the professional background necessary for an online psychotherapist?

A: To conduct complex or comprehensive interventions, a person needs to be well-trained in one of the traditional mental health professionals, then some additional training in online clinical work specifically. However, in the future, we will see more paraprofessionals working with short-term or less complex intervention approaches.

Q: Which are the possibilities to understand the sexual perversions, that are so difficult to approach in the traditional psychotherapeutic setting?

A: Online work may be a good way to begin treatment with such problems, in part because the shame and guilt associated with such perversions makes it difficult for people to seek out and cope with face-to-face therapy.

Q: In your article: "Psychotherapy in Cyberspace" you say that "We can think of computers as handy tools to be incorporated into pre-existing approaches": How do you think this incorporation will be done? Which could be the advantages and the disadvantages of this incorporation?

A: The way computers would be incorporated will depend on the type of therapy. Some behavioral and cognitive interventions that involve specific protocols could be adapted to computers that guide the client through the protocol, assess the client's progress, and then direct the client to subroutines of protocols based on that assessment. In talking cure psychotherapies, computer programs that involve experiential learning and self-insight might be useful supplements to the therapy. They can serve as a springboard for discussions between the client and therapists. During the intake and assessment phase, computer programs might be very valuable in helping clients decide what type of therapy they would be interested in and could benefit from..... The danger is relying too heavily on computers, thereby losing the necessary human relationship between client and therapist that is so important in the curative process, as well as losing the keen eye of the clinician who can see subtle, complex variables in the treatment process that computers could never detect.

Q: The absence of body language, facial expression and speech style cues makes cybertherapy ripe for projection on both side of relationship: which are the possible consequences for the therapeutic process?

A: In a psychoanalytic therapy, the client's projections and transference reactions would be very valuable and essential to the therapy progress. Hopefully, the online clinician is skilled in understanding and working with countertransference reactions, which may be intensified in cyberspace. All clinicians working online should be sensitive to this increased likelihood of projection, transference, and simply misunderstanding what a person means in his/her typing. If not, then these phenomenon could disrupt the therapy.

Q: How do you think it's possible to use the Internet regression in an online psychotherapy?

A: In therapies that encourage regression as a means to understand and repair underlying conflicts and deprivations (such as psychoanalytic therapy), this could be helpful. However, severe regressions might be difficult to handle effectively online since "in the moment" feedback, discussion, and working through might be necessary - which is not possibly in asynchronous communication, like email.

Q: Do you think that individual's anonymity have any negative effects on therapeutic process? Which ones?

A: In an ongoing therapy, if that anonymity involves the therapist not knowing important aspects of the person's identity and lifestyle (living situation, employment, marital relationships, race, age, even gender), it could hinder the therapy, just as it would in f2f therapy. Most talking-cure, insight therapies are a process of coming to know and understand the client better. Using internet communication to "hide" some aspects of one's identity would probably tie the therapist's hands behind his/her back...... If we define "anonymity" as the lack of f2f cues (and not as the hiding of aspects of identity), then the resulting disinhibition may lead to clients discussing aspects of themselves and their lives that they never would in a f2f therapy. This is one of the great benefits for online therapy.