John Suler's The Psychology of Cyberspace
This article created May 1996, revised Aug 98, Aug 07 (v2.0)

Online Therapy and Support Groups

Of particular interest to clinical and social psychologists are those groups with a therapeutic, remedial, or supportive aim. These could include formal group therapy led by professionals, as well as self-help organizations. Such groups can exist as mailing lists or discussion boards, in which the meeting is asynchronous, or in conference, chat, and instant messaging environments, which involve synchronous communication. No doubt, the differences in group dynamics are great depending on which format is used. Each format also will have its advantages and disadvantages.

Mental health professionals are beginning to experiment with online therapy groups, and some well-known self-help groups have already extended into cyberspace. Many more are likely to appear. One of the powerful advantages of cyberspace as compared to the "real" world is that people with similar concerns easily can find each other and form meetings. Geographical distance makes no difference. In the tradition of in-person self-help organizations, these online groups truly are a grass roots phenomenon.

Online communities - such as MUDs, MOOs and multimedia communities such as Palace and Second Life - also may be therapeutic for some people. Experimenting with one's online identity and new ways of relating to others can result in insight and may help people work through personal issues. Under ideal conditions, those changes generalize to the face-to-face world. As one person once told me, "This community is like training wheels... I try out new ways of being, and then I apply it to my real life." Mental health workers who participate in and act as consultants to such communities are developing a type of online community psychology.

Online Disinhibition

It's well known that people say and do things in cyberspace that they ordinarily would not in the face-to-face world. They loosen up, feel more uninhibited, express themselves more openly. Researchers call this the online disinhibition effect.

The impact of this disinhibition effect on an online support group might be positive or negative. Because honesty and self-disclosure are important therapeutic ingredients in such groups, the disinhibition effect could accelerate the groups’ beneficial effects on people. Group members might share very personal aspects of themselves, their problem, and their lives. They might reveal underlying emotions, fears, and wishes, as well as show unusual acts of kindness and generosity. As a result, interpersonal intimacy and group bonding may accelerate more rapidly than in in-person groups.

However, the disinhibition effect may not always be so benign. It can also lead to rude language, harsh criticisms, anger, hatred, and even threats. Some group members might act out in ways that disrupt the group’s cohesion. For some people, self-disclosure and intimacy might develop too rapidly resulting in regret, anxiety, and a hasty termination of membership. On the positive side, disinhibition indicates an attempt to understand and explore oneself, to work through problems and find better ways of relating to others. On the negative side, it is simply a blind catharsis, an acting out of unsavory needs and wishes without any personal growth at all.

What causes this online disinhibition? Several factors are operating, many of them driven by the qualities of text communication. For some people, one or two of these factors produces the lion's share of the disinhibition effect. In most cases these factors interact with each other, supplement each other, resulting in a more complex, amplified effect.

Anonymity:  In an online support group, people do not necessarily know each other’s identities. People only know what other people choose to reveal about themselves. Clearly, in the history of many 12 step programs, anonymity has played an important role in people feeling a level of safety in the group that enables them to self-disclose. Online support groups may carry that anonymity to a new level. When people have the opportunity to protect their real world identities from the occurrences within the group, they feel less vulnerable about participating and opening up. Whatever they say or do cannot be directly linked to the rest of their lives. Group cohesion and trust develops from this reassuring knowledge that what happens in the group stays in the group.

Invisibility:  In the text communication that is common to almost all online support groups, people cannot see each other. They may not even know that a particular person is present. Invisibility gives people the courage say things that they otherwise would not. This power to be concealed overlaps with anonymity because anonymity is the concealment of identity, but there are some important differences. In text communication people might know a great deal about each other’s identities, but they still cannot see or hear each other, which amplifies the disinhibition effect. Group members don't have to worry about how they look or sound, which might be an especially powerful facet of disinhibition in groups that address personal problems affecting physical appearance or speech. Also, there are no frowns, shaking heads, sighs, bored expressions, or other subtle and obvious signs of disapproval and indifference that would otherwise inhibit people. In everyday relationships people sometimes avert their eyes when discussing something personal and emotional. It's easier not to look into the other's face. Text communication offers a built-in opportunity to keep one's eyes averted.

Delayed Reactions: In the asynchronous communication of some online support groups, people may take minutes, hours, days, or even months to reply to each other. Not having to deal with someone's immediate reaction can be disinhibiting. Immediate, real-time feedback from others tends to have a powerful effect on the ongoing flow of how much people express. In e-mail and discussion board groups, where there are delays in that feedback, people's train of thought may progress more steadily and quickly towards deeper expressions of what they are thinking and feeling. Some people may even experience asynchronous communication as an opportunity to temporarily “get away” from the group after posting a message that is personal, emotional, or hostile. The freedom to leave and reenter the group can help people therapeutically manage the emotions that the group process stimulates, thereby encouraging disinhibition.

Solipsistic Introjection: In text communication, group members sometimes feel that their mind has merged with the mind of other members. Reading another person's message might be experienced as a voice within one's head, as if that person magically has been inserted or introjected into one's psyche.  Consciously or unconsciously, people assign a cognitive representation to how they think others look and talk. Another group member then becomes a character within one’s intrapsychic world, a character that is shaped partly by how the person actually presents him or herself via text communication, but also by ones expectations, wishes, and needs. As the character now becomes more elaborate and real within one’s mind, one may start to think, perhaps without being fully aware of it, that the typed-text conversation is all taking place inside one’s head, where it is safe to say almost anything. This process might involve transference reactions that cause a disruption of interpersonal misunderstandings within the group. However, solipsistic introjection can also enhance empathy, bonding, and the identifying with other group members that is critical in a support group, especially if the group understands and knows how to work with these transference distortions that are common in text communication.

Neutralizing of Status:  In online support groups, people don’t see the trappings of status and power - the fancy office, expensive clothes, diplomas on the walls, or books on the shelves. They don’t necessarily know about each other’s “position” in the face-to-face world. In addition, a long-standing attitude on the Internet is that everyone should be equal; everyone should share; everyone should have equivalent access and influence. Respect comes from one’s skill in communicating, the quality of one’s ideas, and one’s integrity as a person. Everyone regardless of status, wealth, race, gender starts off on a level playing field. These factors combined tend to reduce the perception of authority that can inhibit people from speaking their minds. The neutralizing of status that encourages people to self-disclose is especially important in online support groups which historically have emphasized peer-to-peer assistance, rather than reliance on professionals or other authority figures.

Of course, the online disinhibition effect is not the only factor that determines how much people open up or act out in cyberspace.  The strength of underlying feelings, needs, and drive level has a big influence on how people behave. Personalities also vary greatly in the strength of defense mechanisms and tendencies towards inhibition or expression. People with histrionic styles tend to be very open and emotional. Compulsive people are more restrained. The online disinhibition effect will interact with these personality variables, in some cases resulting in a small deviation from the person's usual behavior, while in other cases causing dramatic changes.

Lessons from eQuest

In the psycho-educational program known as eQuest, people engage in a variety of online activities in order to gather information, better understand, and hopefully resolve some personal issue in their lives – for example, issues related to suicide, alcoholism, divorce, self injurious behaviors, alzheimers, ADD, and grief. One of those activities is to find and participate in an online support group that addresses the issue the eQuest participant is exploring. The experiences of people who have completed the eQuest program reveal some of the pros and cons of such groups that affect their sense of empowerment in resolving their issue.

Given that there are thousands of online support groups, finding a helpful one can be hit or miss.  The sheer number of groups is daunting, especially to people who are who are not knowledgeable about searching the Internet. Some groups present vague or inaccurate descriptions in web page listings. Many are small or inactive, while others may seem overwhelmingly large and busy. Although there are so many support groups covering what seems to be every imaginable topic, a person may still experience difficulties in locating a group devoted to a particular issue, especially issues that are rare or very specific, but sometimes even those that are fairly common. For example, one eQuest participant, a college student, could not locate a group that addressed the topic of test anxiety.

After joining a group, the next challenge is to evaluate whether it is appropriate, and, if so, to integrate oneself into it. Participants in eQuest are encouraged to quietly observe a group for a week or more, in order to get a sense of its members, how it functions, and its norms about appropriate and inappropriate behavior.  Doing so will help the person decide whether to stay in the group, and, if so, how to introduce oneself to it. That first post to the group can be a crucial first step in the integration process, and should be considered carefully. Whether the group offers a warm and supportive reception to that first message, responds with criticism or an off-putting comment, or completely ignores the message, can have a big impact on the newcomer. The newcomer should consider friendly, unfriendly, or mixed reactions as possible indicators of deeper dynamics within the group. Because the personality and operations of online groups differ widely, even among groups devoted to the same issue, participants in eQuest are encouraged to “shop around” to find a group that is the best fit for themselves. For example, some people may decide that they have a decisive preference for groups that employ either synchronous or asynchronous communication. Others might decide that they simply don’t like any type of group that relies on text communication. Concerning all aspects of the group experience, eQuest participants are instructed to trust their “gut” reactions. If something about a group doesn’t feel right, leave it.

Once they have joined an appropriate group, eQuest participants report similar experiences about the pros and cons of an online support group, not unlike in-person support groups.  It takes time to feel comfortable about participating and to develop a coherent image of who the different group members are, more so than in a face-to-face group where visual appearances help solidify one’s impressions of others. Some report problems in identifying with other group members who seem very different from them. Many appreciate the level of sharing they experience in the group, the support members offer each other, the lack of criticism and judgment, and the diversity of information related to the issue being discussed. They are impressed by the variety of personal perspectives that different group members bring to the group, which often is the byproduct of the group being online and drawing members from diverse geographic and socio-economic locations. Some worry that they don’t have anything significant to offer the group. Often the stories told by particular people have a big impact on them, usually people with whom they identify, or people who are mastering dire versions of their own situation.  Despite the diversity of people, backgrounds, and experiences being discussed in the group, the eQuest participants were most impressed by the therapeutic factor that plays an critical role in all support groups: the realization that other people share the same difficulty, that one is not alone in struggling with a problem.  Some eQuest participants, not fully understanding the potential power of online support groups, were surprised or caught off guard by the intensity of their emotional reactions to experiences within the group. Curiously, almost all of the eQuest participants who were college students, although quite active in cyberspace, knew very little about online discussion groups. As such, the support groups were a new experience for them.

Aside from the group itself, eQuest participants were also influenced significantly by one-on-one relationships that they developed with other group members. Contact with those people outside the group, usually by email, helped them on a more intimate level of sharing, while also assisting them in better understanding and adapting to the group as a result of mentoring from these people.

In some cases, eQuest participants were concerned about the beliefs and information promulgated by their groups. One college student, who had taken a course on autism, questioned some of the “facts” about autism endorsed by a group devoted to this issue, resulting in a negative response from other members. Another person, a “cutter” who wanted help with her self-injurious behaviors, worried that detailed descriptions of the stress-reducing aspects of cutting might trigger members into pursuing this activity. She also perceived another group as endorsing and perhaps even idealizing cutting as a type of fashion statement, not unlike various types of body piercings.

Such reports point to phenomena that deserve careful study by researchers of online support groups. Although the emphasis on peer-to-peer help can be very therapeutic, some support groups might develop blind spots and promote misinformation if they are too rigorous in their need to reject professional knowledge. They might reinforce their maladaptive belief system when they selecting pick and choose or reinterpret findings from the body of scientific research.  Blatant hostility towards authorities and the stifling of opposing ideas within the group may be symptomatic of an overly rigid belief system. Research on “ideology” in successful self-help groups suggest that each group develops its own particular system of beliefs and attitudes that serves as an antidote to the maladaptive beliefs and attitudes that perpetuate the particular problem shared by the group members. The vast number and types of online support groups provides a fortuitous opportunity for researchers to study the role of ideology in support groups, including how people join groups that either reinforce or remedy the maladaptive beliefs underlying their problem, and how groups may develop different therapeutic ideologies that address the unique needs of their particular members or the unique aspects of a specific variation of the problematic issue.

See also in The Psychology of Cyberspace:

A Comparison of Online, E-Mail, and In-Person Self-Help Groups Using Adult Children of Alcoholics as a Model.

Psychotherapy and Clinical Work in Cyberspace

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