![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu
Revised: October 16, 2000
URL: http://www.dr-bob.org/babble/social/hypotheses.html
Posted by Dr. Bob on October 5, 2000, at 10:09:11
I belong to a group of therapists who are discussing the use of the Internet with patients. John Suler has formulated some working hypotheses (the numbers in parentheses), and I've selected, adapted, and regrouped them with Psycho-Babble specifically in mind.
This is a compilation of the discussion that has followed, with some revisions of the hypotheses. Some of the comments are responses to the hypotheses, others to previous comments.
Abstract: A lengthy, useful, but not altogether accurate "first pass" at describing the nature of online support groups.
I don't believe that is necessarily true. A lot of people with this type of history communicate via the net because they want to be heard, not because it's safe.
I agree. But maybe they're more willing to express themselves, and be heard, online because they feel safer there?
That's probably true. But I'm not sure that safety would be a major concern for me if I just needed someone to listen. Desperate times demand desperate measures.
There's things we can't tell directly to someone. It's easier to write them. Especially things regarding emotional feelings. When I will be a therapist I will just mention to my patients that I've an e-mail address, and they can leave comments on it between therapy sessions if they have something to say...
Maybe it should be "safer" (than communication in person). And maybe it shouldn't be so specific, maybe it's a more general phenomenon...
Anonymity can confer a sense of safety, but not necessarily a feeling of trust. Online communication without anonymity confers neither. I'm wondering how, and/or if, meeting f2f (as some Babblers have) affects this effect.
My hypothesis would be that people feel safer online, even if they're not anonymous. Not necessarily completely safe, but safer than they'd feel in person. How about that?
I think trust is a great issue to consider. What goes into trust?
I can't generalize about others -- I'm just not enough like them. Without anonymity, online communication would feel *less* safe to me than f2f; I would be unwilling to communicate in writing about personal matters to someone I did not know and trust. Any form of writing can be saved and come back to haunt. F2f communication, whatever its content, is ephemeral.
For me, "safe" is a real-time feeling generated by the experience of acceptance. "Trust" is the expectation of future reliability and consistency. It is generated in part by early experiences of consistent caring and in part by recent repeated experiences of feeling understood and valued. Some people's early experiences inoculate them against having such expectations of others.
Overall true. But people might also not write things they feel guilty about, since it leaves a permanent document.
I would say initially more safe, but then things can come up which make them feel less safe than they originally felt. e.g., initial support that turns into criticism.
Yes, but sometimes the personality that comes across in text is one that is rarely exhibited in person, or the relative intensity of that aspect of the personality is different, ie, some aspects find expression in writing and less so in person, and vice versa. Writing gives the opportunity to play and try out different aspects of our personalities.
I think that's very true. I see that in myself.
Yes. The current emotional state of posters comes through clearly. It's been interesting (and somewhat disheartening) to me that my written communications are every bit as socially inept as my f2f efforts.
Possibly. But I think you're on a slippery slope. People may change style on purpose without a change in mood or thoughts. How will you distinguish the two?
Probably true.
Partially, but I think it also represents a need to protect themselves from others getting too close.
It protects them if they choose a handle that's different from their name? One that's more generic? Maybe in that case their wanting to protect themselves is itself one aspect of their personality that's reflected -- indirectly -- in their handle.
Ok, I can live with that. I thought your comment about "generic" was particularly interesting. I've see some people using handles that are so generic that it's nearly impossible to determine whether they are male or female. Although I think a person's writing style eventually brings that info to bear.
There's another gender-related issue. And another hypothesis!
Probably so, at the moment of choice, but this is just a snapshot-in-time which may not have any long-term import.
I would have to say yes; maybe there is a difference between first name people and last name people, and other than idea as name people.
Yes, I think that having others visit your website is incredibly significant, and a risk, if the person has also disclosed personal info and feelings in a forum like this.
Absolutely true.
I have no idea if this is true for others, but, for that subset of us who are in the information business, personal websites usually reflect interests, not personality, and represent professional contributions, not emotional mirrors. Often, visitors have more to do with how the site is promoted and the value of the site to other researchers. It may be mildly gratifying to have visitors, but hardly emotionally significant.
Part a, I don't agree. Part b, definitely. In fact, I think hospital patients should be given access to the net.
Emotionally significant? I would say a web site reflects aspects of their personality, but visiting them for me is not emotionally significant.
Very much so, at times. For me, a significant problem is that a big part of my sense of self that is negative, is non-verbal, and feels beyond the reach of language. Writing helps in the attempt to bridge my cognitive/logical/verbal self to this non-verbal sense of self. I wonder if others have similar experiences?
Writing is the purest form of expression and self-recognition.
It's hard to disagree with a statement this general. However, the degree of benefit that writing confers may be affected by the degree of impulsivity the writer exhibits.
Definitely yes for the first two. [Somewhat] for the 3rd point.
Definitely. "Chat" rooms in real time tend to get kind of primitive. That happens here, too, though, and people can still be somewhat impulsive and reactive in this format, too, but less so than in real time. At the very least, even if they are as impulsive, it isn't as disruptive to other threads of conversation as it is in a real time chat format.
For some perhaps, for others like me (especially during manic episodes) it gives you the opportunity to speak what's on your mind without fear of immediate recrimination. I often go back and read my own posts and wonder "Did I really write that?"
Not necessarily. Even "real time" chat has a composing/reading delay. And we've seen some pretty impulsive, "thoughtless" posts on this board.
Agreed.
I would say perhaps enhances self-reflection and cognitive association, but I'm not sure about impulse control. Do you mean from self-harm? Maybe. But writing on the internet can be an immediate action that makes expressive impulse control, not necessary, i.e., someone can respond with anger on the internet without waiting until the next day and realizing expressing the anger in that way is not appropriate.
Yes, I agree, and with the added benefit of not worrying if you are "bothering" them, ie, it is there for the other person to read at their convenience.
Only if the person replies. If you post to a specific person, and that person doesn't reply, how can that possibly make you feel as though they are available?
I really don't see this one. I believe that in advance of, or in the absence of, replies, posters' anxieties and/or self-doubts may actually be heightened.
Yes, but it also helps knowing that you can be of help to others.
Without replies one can feel more isolated; with replies, I would agree.
Definitely (similar to my comment above).
Interacting with someone via the net and talking to that person f2f, are two completely separate animals. I can hone my communication skills on the net, but that doesn't mean I will be successful using those skills in real life.
I'll be interested in Babbler's responses to this item. Personally, as a result of what I've learned about myself online, I make far *fewer* attempts to connect with others offline. So, I guess that the second statement is true for me.
Only for outliers, but they should be removed from your sample.
Don't think so.
The overwhelming benefit of on-line communications is of course, the chance to "freely" express oneself and see how it measures up to what one imagines the responses to be.
I have found this so. I feel much more empowered as a patient, to be able to find information so easily about medications, different health issues, etc.
This is the only point I totally disagree with. Having been a 'late comer' to the internet, I'm sure that any dramatic change in myself, relating to internet use, would be extremely noticeable. Whether "online" or not, I have found the gathering of information to be neither "empowering" nor "transformative". I think that adding to one's store of knowledge could not empower or transform, unless the information is accompanied by a 'guide' (therapist) who would lead one to use the knowledge correctly, in order to be transformed, which would then lead to empowerment.
Interesting point, and I think a lot of doctors would agree with you, that patients need doctors to filter and guide the information.
However, the internet, for me, has given me unprecedented access to a wealth of information about health issues of interest to me, and being able to educate myself in this way has enabled me to seek out the care I needed. I would absolutely not have been able to do that without the internet.
This doesn't at all substitute for any of the doctors I see -- psychologist, psychopharmocologist, endocrinologist, gynecologist, internist. It has empowered me to ask the right questions, to work more collaboratively with my doctors. In the case of the endocrinologist, it actually allowed me to find the right doctor for me (through a recommendations page on a thyroid site).
At Syms, they say, "where an educated consumer is our best customer" and I think this is true a millionfold when it comes to healthcare, particularly in today's health care environment, when the average doctor spends about 4 minutes with each patient.
I have a "team" of very smart, talented, skilled, highly trained experts, whom I could never replace with internet information. But I think of myself as my own health care case manager, because there is no one else coordinating all the different elements of care, trying to integrate them and look at the whole picture. This role, which was only possible with the help of the internet, is the "missing puzzle piece" I needed.
If the info is clear, concise and understandable, then I agree with this statement. If the info is masked in "Doctor Speak", then it can be very intimidating.
I understand what you're saying, but what about "access" in general, given that some information is clear and some is intimidating? Would you say that access to that mix of information tends to be empowering and transformative?
From my experience, one can be transformed without being empowered -- and vice-versa. I think that information leads more often to empowerment than to transformation.
Depends on the information. Overall, I would say no. Besides, the info on the net is not always reliable.
Definitely empowering. It's good to go to my pdoc with a good sense of what's out there for depression, what are possible side effects, etc., for example. Transformative, I would say rarely, but possibly.
Don't we know it!!
Depends on what is being said and how important the subject matter is to the person reading it. There is no black and white here. A lot of subtle shades of grey though...
Personally, I doubt it. I believe that most misunderstandings arise from hearing/reading the communications of others through personal filters or biases. I'll bet that visual stereotyping causes as many misunderstandings as other visual nonverbal cues avoid.
Disagree. Because it's written, the cognitive and emotional processes at hand reduce the likelihood of misunderstandings ... despite the absence of tones and facial expressions, body language, etc.
Probably, but not to a significant degree. You can always, respond to clarify meaning -- it just might take a bit longer.
One of the downfall of on-line communication is having the DEGREE AND DEPTH of one's emotions/actions misunderstood.
Yes, hearing something once, the idea might be lost, and thus not integrated as an "internal voice", but somehow having access to "quotable" text allows us to visit and revisit ideas which facilitates integration.
Depends on whether the communication is positive or negative. Positive feedback can breed positive self reinforcement. Negative feedback...well, you get the point. Perception is everything.
I agree, the internal voices could be good or bad, so this should go in the "potentially positive or negative" category.
Probably so, if you're emotionally equipped to accept and/or believe others' expressions of positive regard. Some of us, however, appear to have flunked the child psychiatrist Erickson's first developmental stage -- "Trust vs. Mistrust."
Not always true. For instance. I've seen some responses to suicidal people which I consider to be criminal. People with no training in suicide prevention can do a great deal of damage.
Yes, as I wrote about in an earlier comment. Mostly, I think this is a positive potential, however, I think that it could also provide opportunities for expressing negative, even dangerous aspects of personality, as well as opportunities to "practice" these aspects and gradually loosen inhibitions, to the point that someone might turn to actually acting out these aspects. I think this is an especially important issue with kids, because their personalities are still developing, and are more vulnerable to this influence.
I think once you get to know your "audience" this is very true. For most people it's a matter of trust. I discuss things about myself at my own website and one other that I frequent that I would never consider discussing here. Why? Trust, pure and simple. I have come to know, love and trust those people, and the door swings both ways.
But, is the "confessional" behavior observed a function of online communication, or only of *anonymous* online communication?
True and not true. The permanence of these records and the possibility of being identified will reduce this for many taboo issues.
I suppose this is true.
Well, if one is affected at all, s/he is likely to be one or the other [ie, either more inhibited or less inhibited], don't you think?
Right. But do you think there's likely to be an effect? And, if so, which one? :-)
People who join either an online or offline group do so because of some need to communicate with others. There *are* communication differences between the two group types. However, they seem to me to be perceived differences in timing rather than in style or content. An online member may seem to reveal more sooner, but that may be because they have been a "virtual" member (lurker -- an unfairly derogatory epithet, IMO) long before they became active (visible) by posting. Factoring out timing, I suspect that communication style and content are pretty similar across group types. They are for me, at least.
Not clear.
Once again, I think this depends on how well you know the people you're talking to.
In some respects, yes. In other respects, no.
Disagree, usually not more guarded about true self. If true self is depressed, it's easier, (or maybe more appropriate) to express on the internet, rather than to an acquaintance.
Yup! I agree this could go either way -- either to enhance development, or to shield from taking "real" and necessary risks.
True.
Quite true. I wonder how many will read/hear this statement as meaning its reverse?
Definitely. But it does not replace intimacy. In some ways, it's better.
If you are talking about quoting sentences out of a poster's paragraphs for the purpose of responding, I think it is ridiculous and irritating. If you are talking about posting your reply above or below the original message, I do that all the time. It allows me to refer to the original so I can make sure I've answered any questions asked of me.
Certainly. It "can" also be used to preserve valuable information for later use, or any number of other possibilities.
Mostly yes.
Yes, and that is one reason it is so useful for people with social anxieties.
I imagine it can and does. But I've also seen negative social interaction force people into hiding. Once again, it depends on the type of interaction, positive or negative.
Right, this should also be moved to section D.
This can only be true if the previous statement (7.2, 7.3) is true -- ergo, this is a corollary. Perhaps it can, but *does* it? I think its clear that writing reflects life, but unclear that life reflects writing.
Online communication can also isolate people from real social interaction.
Disagree, online and inperson is too different; there are not as many consequences for online, e.g., "if you don't do what I want on your board, I'll leave and go to another board or start my own board."
I think that depends on subject matter. Sometimes you have advice or info, sometimes you can only let a person know that they are in your thoughts and that you are wishing them good luck. Sometimes you are best served just to keep your mouth shut. I guess as a generic statement, this is mostly true.
More quickly than what? Do you mean "People with problems can find advice/support more quickly online than from other sources" or "People are more likely to respond quickly to an online call for help than to a similar request in "real life"?
Sorry, that was poorly worded.
Depends. Others can also add fuel to a fire.
I think online therapy would be great for a subject with a say, split personality. Online communication would help the therapist identify the branches at a faster rate. Collect more pieces. Just a thought.
Definitely!!!
Absolutely! A successful support group must have one golden rule, respect. And as painful as it may be, someone has to enforce the guidelines.
Most "groups" respond positively to a sense of direction and a certain minimum of structure. I believe that these are absolutely necessary for a support group to be experienced as supportive.
I disagree. What would be useful would be mental health workers checking some of the info, and providing feedback regarding the accuracy of some of the statements.
What would be useful, if not a necessity, would be a list of suicide prevention do's and don'ts at the beginning of such web-sites.
True.
Less cohesive than what? In-person support groups? Perhaps.
Depends on the closeness of the group. People who have been together for a long time tend to be very cohesive, perhaps because you get to know each other's moods and personalities. A site where there are a lot of new people coming and going, such as Babble, may not be as cohesive simply because you don't know everyone as well. It's again a trust issue.
Good point. To simplify things, I left out part of the original hypothesis, which was "due to the traditional cybercultural assumption that one can join or leave, respond or not respond, as one wishes".
This would seem to be a factor of membership stability -- or lack of it.
No shit!
True.
Yes, and this can be helpful to a person who is just getting their feet wet in connecting with others, but it can also lead to big problems, as we all know here.
For some that's very true. But those are generally people who like to play games.
I doubt that the personae of most are quite so "fluid." I believe that differences seen are more often reflections of a complex "true self."
Absolutely! But is it healthy?
Could, but I don't know how many people do. Seems like a small percentage.
If you haven't used the internet/newsgroups before there can be a very big barrier to getting started. I read various groups for about a year before actually getting around to posting (I don't have home PC, and was reluctant to post from work, also didn't really understand how private groups are. I now know that some are not very private, you can be traced through IP addresses etc.).
So it was not wanting to be traced that kept you from posting? And once you learned more about the issue, you felt reassured?
Before you started posting, did you feel comfortable enough to make use of any offline alternatives?
Finally, I think it's significant, and probably worth making into another hypothesis, that online groups can be easier to join because it's possible to get comfortable with them by lurking before participating more actively.
Yes I was concerned about privacy. Eventually I figured it was reasonably 'safe', but I was also a little worried about doing things wrong, looking foolish, or getting some kind of abuse back
I had been to see my GP, but hadn't managed to get a referral to a specialist, so turning to the internet was me getting desperate to help myself
It may not be obvious to a newcomer how to post anonymously, which is a barrier.
Getting positive feedback can give you a boost, but criticism or negative feedback is very damaging when you are depressed.
Just posting and getting things off your chest is a help, but getting no replies to your messages is very damaging emotionally (makes you feel worthless that no one could be bothered to reply.
Dr. Bob
Right, this is along the lines of what Greg was saying, there are two sides to some of these issues.
You can get a feeling of being part of a community, but I think this is largely illusory. After returning to a group after a few months I realised I had no meaningful connections left from the contacts I knew before, which made me feel very lonely, and also that the previous interactions were a waste of time.
Dr. Bob
Hmm, when you returned, the people you knew before weren't there anymore, or they were still there but the feeling of being connected to them wasn't?
Just because something doesn't last doesn't necessarily mean it's a waste of time...
Leonardo
The ones I knew were gone, that was the shock, as the community I knew had 'disappeared'.
Remember we are depressed people who don't always think logically! I can get from a minor mishap to thoughts of suicide in about 3 moves! At the time, I was grieving the loss of a friend (who went away) and a relative (who had died). This creates a feeling of 'aloneness'. I returned to the message board I used to frequent looking for an anchor of stability. When it wasn't there (or the people anyway), it reinforced my feeling of loneliness. In particular, I had the feeling that I had deluded myself into thinking I was making 'friends' or meaningful contacts, when in fact they had just evaporated. As you say, it wasn't a waste of time (I learned some useful info and felt supported at the time), but I felt it hadn't help to move me forward in terms of me making any real connections with the rest of the world. (Disconnection is one of my problems....)
You can definitely get addicted, and rely too much on what you expect to find from the group. Occasionally you can get a gem of support or information, but mostly not on the whole I have found.
Dr. Bob
That's an interesting idea, that you might find gems online, but not enough to make it really worth looking for them there.
Wow, how interesting!! Throws a whole monkey wrench into theory on transference/countertransference. Can you explain the "twins" concept??
What kind of a monkey wrench?
Regarding twins, adapted from NPD Central:
In ... the twinship or alter-ego transference, the patient perceives the therapist to be psychologically similar to himself or herself. Conceptually the patient perceives the therapist and himself or herself to be twins, separate but alike. In the twinship transference for the selfobject cohesion to be maintained, it is necessary for the patient to view the therapist as 'just like me' (Manfield, 1992).
Well, I guess I was thinking about how more traditionally psychodynamic therapies bank on the patient forming a transferential relationship with the therapist that is based on a child:parent relationship, which, of course, involves a difference in perceived status, as well as the actual difference in status because of the doctor:patient set-up.
If it is true that online communication levels the balance of power somewhat, then, online communication might be a good fit for approaches, such as feminist psychotherapy, that try to minimize as much as possible, this power differential.
On the other hand, we have witnessed here all kinds of projection onto you, Dr. Bob, about the power you hold as the moderator/owner of this site, and I would venture to guess that whatever way people relate to your authority, they would do so in person or in text, ie, either way, the style in which they react to authority would be expressed.
This [twinship] concept has always seemed a bit fuzzy to me, I must admit. Perhaps because the therapists I have had are men? I wonder if this twinship phenomenon is stronger in same gender pairings of therapist and client, and I wonder how gender issues are affected by communicating online rather than in person.
Another thing about twinship: isn't humor (laughing at the same joke evokes a sense of alikeness) something that would facilitate this, and how is humor affected by the online relationship vs. in-person?
Ah, I see what you're saying. But maybe there could still be other transferential relationships?
I don't know about this one. We have experts here, some who are approachable on a personal level and others who aren't. It depends on how I can talk to them in how I perceive them.
Another good point. Maybe the key isn't being online, but in fact how approachable the "expert" is.
True. An online "group" has, almost by definition, only 2 levels -- the moderator/administrator and the participants. Formal status is automatically conferred upon the first. Informal status may be awarded to those participants (and leaders) whose contributions are perceived as valuable.
Depends on the sophistication of the population. On one site, when an identified psychologist responds, it is taken much more as "authority" than other peers. I don't know if that would happen on this site.
Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu
Revised: October 16, 2000
URL: http://www.dr-bob.org/babble/social/hypotheses.html