Online Therapy: A New Frontier

Kylie Coulter

Without further ado, Kylie, what made you decide to pursue a diploma in counseling/ bachelor’s degree in psychological science?

When I was 16, I developed an interest in psychology and philosophy and after taking a career test in high school it was discovered that counseling/psychology or forensic psychology would be a good career choice for me. After pursuing a career in sales, which I found very unfulfilling, I decided to do a course in counseling.

By the age of 19, I was studying counseling and after finishing my counseling diploma, I decided I wanted to take my education as far as I could, so I applied for entry into The University of New England, N.S.W, Australia.

Next year I will be 26 and completing my honors year. I’ve found I have a moderate aptitude for psychology and have therefore set my sights on, eventually, a PhD. I would like to specialize in applying therapeutic interventions online.

What made you decide to try online therapy and how did you first go about doing it?

After attaining a counseling diploma in 2007, I discovered the internet as a vehicle for therapeutic interventions and began providing free counseling to anyone who wanted it—sourcing client’s mainly through Myspace. I was amazed at how busy I became, I made it quite clear I was a student in training; no-one seemed to mind as they just wanted someone to talk to.

After promoting my free services in the virtual world of Second Life, I began forming waiting lists just to cope. I allowed my services to be reduced when university became busy, but now that I can see the end of my degree I’m very keen to get my services running to full-steam.

Could you please describe what types of therapy you have conducted online and in what forms?

I have conducted therapy using video conferencing, voice conferencing and text counseling using many different chat programs. I often use the chat program the client requests and operate on the clients time. It takes the hassle out of everyone working out time zones. These days I know the time of various countries, you get used to it. I have conducted individual therapy and relationship therapy in Second Life (the virtual world), through msn, and on Skype.

I use a holistic approach mainly looking at the clients individual strengths and concerns and applying the appropriate approach. Mostly I use a combination of Cognitive Behavioral Therapy (CBT), Brief Therapy, Existential Counseling, Client-Centered Therapy and sometimes, but rarely, psychoanalysis. With relationships, I use the Imago approach.

What would you say is your weekly virtual caseload?

My weekly caseload can be anywhere between 1 – 20 clients per week. Mainly I limit the amount of hours I do because of study.

Could you briefly describe second life for those readers who are unfamiliar with the virtual world and then explain how you go about conducting therapy via this modality?

Second Life is a virtual interactive 3D world conceptually similar to the game Sims (except it is fully customizable and the sims are actually avatars and real people drive them). Therapy in this medium requires a fair bit of knowledge about technology and how to operate in the environment.

I meet clients through advertising in the classifieds, word of mouth (which is my main source) and generally just networking in there (joining relative groups etc). I set up appointments in either the client’s time or using SL time, this makes it easier on the client and most of my clients are American.

Billing can be done through Paypal or through second life as they have their own currency called Lindens. Second Life is not the only place I have my services, I provide them through Skype, Windows Live Messenger and other chat programs.

In fact, I try to encourage my clients to move to these mediums for counseling as they’re under more of my control. Linden Labs (the owners of Second Life) have access to all IMs and while I’m sure they don’t pay much attention, clients need to be aware of this. At least with Windows Live Messenger, our conversations are encrypted (on my end) with bit defender.

What is your opinion of virtual therapy vs. face to face therapy? (Are there some ways in which you find virtual therapy superior to face to face therapy? or vice versa?)

*laughs* This is a large question of which many many pages could be written in answer.

There is much debate on this and I shall answer on my own personal experiences. I have had most of my experience in online mediums, I am at home online and online conversation is a forte of mine, I am sensitive to text and voice and other factors that come into play. However, I conducted my training face-to-face so I have some idea of the differences.

Personally I think for the inexperienced online therapist, trying to navigate in an online medium coming directly from a face-to-face medium can be difficult to implement. While the current generation has grown up with texting and expression in online and digital mediums, most of us grew up with telephones and snail mail; however, I started using the internet for conversation when I was 15.

For most people, face-to-face conversation comes naturally, we’re primed from a young age to recognize sounds, signals that places conversation in a context. Empathy has a large biological component. With online communication, if you haven’t grown up with it you may not be as in tune to the subtleties that come with online interaction.

To me, everyone has a conversational thumb print that gives me an indication of who they are and how they see the world. And I pick that all up in text. It would take many pages to explain just how that occurs. Poets and writers have been expressing themselves and painting pictures with language for centuries. They use metaphor, analogy, certain words with emotional content etc.

These days we’ve enriched that experience with smilies, disclosures such as *laughs* and other various tools to make sure we’re communicating adequately. Humans are very adaptable. So I think comparing face-to-face with online therapy as like comparing apples with pears, they’re both fruit, but very different.

They both have their strengths and weaknesses and the findings speak for themselves. Recent research has found that online therapy is as effective as face-to-face therapy.

Focusing for a moment on your clients from Second Life who remain in the virtual world, do you and your clients remain partially concealed (within an avatar identity) for the duration of the therapy? And are you able to as if sit across from one another within your avatar form?

Yes, your physical identity is concealed if you’re not using webcams. Your avatar becomes a sort of extension of yourself which is why those clients who’re already immersed in the experience of Second Life are much more likely to respond to environmental cues.

Discussion is in IM chat though which means that mostly the avatars don’t play a large part of the therapeutic role. I draw up paint documents on the spot, upload them to Second Life and then display them for clients to see. This way we can use visual aids to better conceptualize and concrete ambiguous thoughts, feelings and ideas.

Our avatars can certainly sit across from each other. Because clients do treat their avatars as an extension of themselves I treat their avatars like I would treat a client in a face-to-face situation.

In what way do you tend to interpret the different avatars selected by your patients?

Just like face-to-face meetings with people, you place their looks within a wide variety of other contexts. Some people treat their avatars very sensitively, while others see them more as a play thing and are always swapping and changing.

I think most people are somewhere in the middle, they see their avatar as something they can change and alter but they also identify with the avatar. I try not to draw conclusions on outward appearances in both real life and Second Life *smile

Do you think that some patients may purposely select a different avatar to be someone else in their interactions with you?

Certainly I think it’s possible. Although in my experience this is not always the case. I rarely have avatars who show up naked, or wearing lingerie and posing inappropriately. People want to make as good an impression in virtual worlds as they do in real life.

Most are dressed what I would call ‘appropriately’ for that given situation. Although, some who take on animal forms in Second Life just show up as that animal. I think people like to play situations out seriously, as much as a paradox that sentence is.

You mentioned that you receive new clients from “word of mouth” – how does this work in SL? And what type of groups do you tend to join to help spread your name?

Word of mouth works through connecting with other people, a bit like online social networks. I suppose someone might have trouble and an ex or current client might recommend my services. Also, there are lots of support groups in Second Life which I try to stay in contact with.

I like to know what is going on in their groups and I like to make myself available to provide advice or even give talks to their communities on therapeutic topics. If you help people overcome perceived impossible problems, word spreads.

Finally, what advice or guidance would you offer either a social worker or psychologist interested in starting a practice in the world of virtual therapy?