Cape Cod 2000 with John Grohol, PsyD and Judith Allen, PhD - Tuesday July 25, 2000
eTherapy – The Beginnings
Hello. My name is Robert “Skip” Bischoff, Ph.D. and I’m one of the ancients in this world of cyberspace. I’m not political nor do I conduct research or write papers about my experiences with the world of telecommunications, so likely none of you have ever heard of me. I am however, along with John Grohol PsyD, Ivan Goldberg MD, and others among the most experienced in the provision of online mental health services to the general public.
Today, Judith Allen PhD and I will be talking about eTherapy, it’s origins and current practice as well as relevant issues. I will be handling the history and development, since I have been doing eTherapy for about 17 years, since the days of the dial up Bulletin Board System, Fidonet relays and when the Net belonged to the military, scientists and universities.
Let me start with a little relevant history.
Before the Net was available to the general public, there were a number of online telecommunications services available, including electronic bulletin board systems (BBS) and major online dial up services such as CompuServe and others.
Bulletin Board Systems (BBS) – individual computer systems running telecommunications software which allowed a user to dial up the BBS, login, and then either read and/or post to various forums/discussion groups/themes on the BBS or request a real time chat with the system operator or SysOp. Also extremely popular in the early days were program and text files, which were available for immediate download, since thousands of novice programmers were trying their hands at creating programs in DOS (the operating system before Windows).
Further, if the BBS was part of a “relay network”, then posts to a single site would be relayed within 24 hours to the next level in the structure of nodes in the network and within about three to four days, to the entire network. This was similar to what we call listservs today on the net. Probably the best known of the relay networks was the Fidonet, which had hundreds of computers networked in this manner, that is, in a tier like structure and a rather wide readership. Generally, it took about a week for a message posted in one location to make it out the the fringes of the entire network of nodes and back again with replies to the original posting.
The discussion groups or forums as they were commonly called were centered on specific issues and anyone could login and read and/or comment in the forum. On ShrinkTank BBS, I had several forums that dealt with common questions from dating to stress to work and sex, the latter always being popular. These forums would be frequently visited and take some interesting turns, since anyone could say whatever was on their minds.
When running these forums on ShrinkTank BBS, I noticed for the first time that people were willing to say the most outrageous things to one another and what became dubbed as “flame wars” would break out without much or any provocation. That is, with the absence of physical boundaries of an individual’s presence or the emotional boundaries of voice and affect, people would express a range of feelings in an unbounded way. This disinhibition was alarming initially; however, over time, it became apparent that it was most useful in the email advice giving I would conduct on ShrinkTank, both in the forums, but also in private messages; today’s equivalent of email in the BBS world of the late 1970’s and early 1980’s. This same phenomenon was evident in real time chats that I occasionally conducted with my BBS users.
This disinhibition was also facilitated by an individual’s ability, on most bulleting board systems, to adopt a false identity, including gender switching, age and ethnicity deceptions, etc. So, most SysOps would require at minimum a verification of your phone number by using a call back system for verification and a user list (which was generally viewable by a BBS member) and at times a voice verification. Further, an individual’s anonymous status was further encouraged by use of a alias or “handle”.
All of these factors contributed to people saying pretty much what came to their minds without worry of social censure or embarrassment. This is one of the big pluses of using the net, particularly email to conduct eTherapy. And like most things in life, the good news is also the bad news, that is, a person can take on any identity they wish and most easily hide any aspect of themselves from the online helper. That being said however, in the many years that I’ve been doing online counseling/advice giving (since about 1983), I have noted that most people try to give any and all information that they feel might be relevant or useful to the online helper and are actually pleased to fill in the holes as much as possible when asked direct questions. I also noted that I was willing to be even more direct than I normally am in these transactions, cutting right to the point with people. In almost every case, the person would respond in a similarly blunt and forthcoming manner.
Jumping back to the historical perspective, about the same time that BBSs where beginning to flourish, a number of large online services were starting up, like CompuServe, PeopleLink or PLINK, Genie, Delphi, Prodigy and The Source to mention a few. If you think about the structure of AOL in today’s world (or CIS for those or you who belong to that service) then you’ll appreciate the approximate structure of CIS or CompuServe and other services in those days. In addition to many online commercial services and advertising, these huge services offered a multitude of online forums, which followed the structure of BBS offerings. I mention these large services specifically, since in addition to the online forums, they also offered multiple user real time chat services, such as CompuServe’s CB (modeled likely after Citizen Band radio channels) channels A and B. In these real time settings, many users could interact as a group with the discussion theme carrying their handle on the left margin and the text of their input on the right and the world of emoticons was born, with smiley faces ;-) and cryptic forms of abbreviation ROFLOL (rolling on floor and laughing out loud) or simple BTW or OIC for by the way or Oh, I see respectively. Since was (and is) very easy to take what a person is typing entirely the wrong way, these emoticons help in clarifying one's intentions.
I quickly noticed two things happening here. The first being the same spontaneous expression of whatever was on a person’s mind, often erupting in a “flame war”, but also that time seemed to fly by since the process was so engaging. My first month’s phone bill was $ 276.00 upon discovering the CB chats rooms! I quickly curtained my involvement, but was even more interested in starting my own BBS so I could chat with users and offer a specialty site catering to psychology and mental health issues, which I promptly did.
Over the years that followed, I offered online chat with users on my BBS site and answered hundreds of emails from users the world over. I would class the questions in three areas generally.
1 – young people asking questions that focus on growth and development issues.
2 – adults asking questions about work and relationship issues.
3 – adults who have been diagnosed as having a mental disorder and wanting to know about the condition and what they can do.
In all cases, it’s important to gain a full understanding of the person’s lifestyle by asking questions of them that otherwise may well be answered by simply “looking at” the person so that your frame of reference is satisfied. It is also important to have accurate real time information about the person, should you need ever to have a “welfare check” done by the police. Fortunately, I have never had to do this, but I always get location and voice phone just in case.
Another advantage to doing online or email eTherapy, which doesn’t often happen in the wet world, is a chance for the person to actually write out the complete problem as they see it, in stunning detail. Like many other questions about life, if one is tasked with really defining what’s troubling them, the solution is often quite evident to them in the telling of the problem. Not to mention the advantage of having a complete transcript of the interactions! In the BBS days, I could “open a buffer” to capture the entire series of transactions of a real time chat as well (and always would should there ever be a problem with understanding or even the remote possibility of litigation).
In the BBS days, security was less of a problem, unless of course a person was using an outdial network service such as TYME NET to contact the single dial up BBS. We had hackers then too, who would delight in crashing a BBS they found offensive or in stealing information from the system they found vulnerable. For this reason, I would transfer my saved “buffered” conversations to a floppy disk at the end of a day so that it would never be available to a hacker. My BBS was only hacked once early one, which is why I took these extra steps to preserve private dialogue.
I have included some examples (real ones) from a multitude of questions I've received over the years to give you a feel for what and how people ask their questions and in most of the examples below, I've included my response.
Thank you for your attention today and please feel entirely free to contact me at your convenience to ask any further questions or for clarification regarding information shared here today.
Dr. Rob "Skip" Bischoff
EXAMPLES - Verbatim from my files
effects of it only lasted a month and then all of a sudden, I got depressed
even while I was taking the drug. My doctor put me on Cytomel 50mg and after a
while, I started to feel better. My doctor said, my brain cells were not
absorbing all of the Zoloft. After a few months, I forgot to take my meds and
so I slipped a little and he then put me on 450mg of lithium. I am so glad I
am feeling a little better but I still get a twinge of that uneasy feeling
every so often............. In April of 1998, I had another bout of depression
which is now under control but now I am experiencing Shortness of breath and
sometimes my throat feels restrictive Could you please help me, my doctor
thinks its anxiety but I don't agree
Thanks
Janet Doe
the meantime maybe you can help me.. My sister is in recovery from
drug/alcohol abuse.(5 months clean) She is also an incest survivor. The
problem is she has a history of cutting herself. Not with the intention
to die but only to have a release. or a coping mechanism as we call
it. These episodes are occurring more frequently and more intense. My
question is this. Is cutting and/or self injury considered an addiction?
Second question : is this considered MICA or dual addiction? She seems
to think that it is acceptable behavior as long as she is not
using/drinking. Denial? Can you please help me to find a study or an
article or support group on this topic. Thanks so much for your time.
Sincerely, Peg
Hello Peg,
Hmmm... Let me just say a few things regarding the description you've given me
regarding your sister. First of all, thank God she is in recovery so that her
mood and behavior might be helped at all by additional psychiatric assistance.
Now, let me say that cutting on oneself is not characteristic of people who are
alcoholic nor of drug addicted, despite the multitude of OTHER very
self-sabotaging and self-destructive behavior pursued. This kind of behavior
is however more commonly seen in folks who have been sexually and otherwise
abused as children. And from my experience, it is most commonly seen in
individuals who are suffering from some of the most serious psychiatric
disorders and absolutely needs good psychiatric intervention and treatment. I
would most strongly recommend, based upon your brief description, that you
encourage your sister to seek psychiatric treatment in addition to her recovery
support (assuming some sort of AA support group going on here?)...
I know that this is not a reference or paper on the topic (try the FREE medline
search engine on my site), but it's a conservative expression of my years of
experience in the field of recovery (about 20 yrs. at this point)... Your
sister needs more help than she is currently getting.
Regards,
Robert
Dear Dr. Bischoff:
son. I got my tubes tied 15 years ago .. Three days ago, I learned that I was pregnant again ...Right now, I am taking 300mg of dilantin, 250mg of mysolin and 450mg tegratol a day... Could you please tell me all the risks that are in place here having a child at my age plus on all this medication ... Thank You
My reply:
Dear Jane,
I'm not a licensed physician, but rather a licensed psychotherapist and am NOT qualified to give any form of advice regarding medications or their synergistic effect upon a fetus. I would strongly recommend that you see your medical doctor for advice on this matter as well as your local pharmacist. If you don't have a doctor, you can call the medical society in any town or county in the US and have them make a free referral to you for a physician to see. In this case, I can tell you that you'll need to see an OB/GYN specialist doctor.
I hope this brief recommendation is helpful.
Good luck with this pregnancy and please, don't put off seeing a medical doctor VERY SOON.
Dr. Bischoff
Example # 4 – with my reply:
I have a question due to a discussion with some friends/coworkers. We somehow
got to the topic of "addicted to love", and now wish to know if there
is a
clinical term for this type of addiction - no, I don't mean nymphomania, I am
talking about, literally, love. Perhaps maybe an addiction to the emotion? Or
the feeling?? I'm not sure.
Any help/advice you could give
would be greatly appreciated.
Thank-you,
Dan Doe
My reply:
Hello Dan,
Now you have asked very complex question and I'll tell you up front that
there is NO simple or even definitive answer. You'll likely find
proponents for both sides of the arguments: one side being the folks who are
members in good standing in SLAA or Sex and LOVE Addicts Anonymous and the
people who view what you're calling "addicted to love" as a
combination of emotionally dependent and obsessive personality types.
The major problem with "behavioral" addiction versus
"chemical" addiction is a war that's been waged in the
recovery/psychiatry community for some very long time. With alcohol,
cocaine, etc. there are fairly clear cut chemical triggers which the substance
activates... with "love" or "gambling" or the like, the
connection is less clearly defined.
Now I'm of the opinion that this debate and sometimes vicious argument will prevail until there's a biochemical process discovered that's underlying
the various "behavioral addictions". Of course, this is the
plight of the intellectual and research community to work out.
On a very pragmatic basis, I have worked with and seen many, many people
who's lives were in various stages or wreckage due to "behavioral
addictions" and their subsequent participation in a twelve step program
like SLAA or GA (gamblers anonymous) or EA (emotions anonymous) or OA
(overeaters anonymous)... etc, basically save their lives, marriages, jobs,
etc.! The very sound principles of the twelve steps are highly effective
in helping people who may be described as addicted to love, food, sex, gambling,
etc.
I imagine that the behavior of someone you know may have been at least in
part the reason for asking my opinion. If this is the case, I would urge
you to highly recommend to this person they seek some professional help and also
to explore participation in the appropriate twelve step program.
I hope this has been helpful.
Regards,
Dr. Robert Bischoff
Example # 5 – with my reply:
to the availability of material on dealing with psychopaths.
that I can proceed in please email me
thank you
Brent Doe
Rob Bischoff wrote:
Sorry Brent, nothing in particular; the only advice is to avoid them at
all costs! and don't ever forget that they operate solely on what's in
their own best interest in almost every given situation...plus they DO
NOT CHANGE!
Regards,
Robert