Telehealth: WOMEN'S INTERNET BEHAVIOR
PROVIDING PSYCHOTHERAPY OFFLINE AND ONLINE FOR CYBER-INFIDELITY

by: Marlene M. Maheu, Ph.D.
Director of Telehealth
California School of Professional Psychology
September, 1999

As women are using the Internet in increasing numbers, a variety of behaviors worthy of psychological study are emerging. Cyber-infidelity is examined as one such disorder, and observations are drawn from several Internet-related surveys chosen to glimpse the changing world of women empowered by the Internet. A typology of cyber-infidelity is offered. More importantly, how the psychological community might prepare to offer ethical, feminist treatment of such new disorders both on and off the Internet is also discussed.

Equipped with a computer, modem, and telephone line, women not only participate, but now also rival men in Internet use. Demographic studies of Internet usage patterns suggest that 92 million adults are reportedly on the Internet; women comprise nearly 50% of users; and women had an 80% increase in making online purchases in 1998 (NUA, 1998). While information regarding the spending habits of women are easy to obtain online, it is more difficult to assess other types of women's Internet-related behaviors of interest to feminist psychologists.

The Internet can be an efficient tool for either self-improvement or self-harm. Savvy users can acquire tidbits of knowledge to full medical journals with a minimal amount of effort. For others, the Internet meets the need for instant, even constant, companionship. It creates a forum where individuals can gain the online admiration of others with intellectual prowess and/or creativity, regardless of their true position in reality. Surfing the Net can allow people to establish relationships that ward off isolation or loneliness instantaneously, freeing them from the unsavory demands and challenges of traditional friendship. It also leaves them open to a variety of unexpected emotions, such as when their secrets are revealed to their online communities, when they are duped financially, or betrayed in love. The Internet offers both glorious freedoms and hidden dangers to those who frequent its cyberwaves.

In an effort to bring some degree of specificity to an area that is fraught with ambiguity, cyber-infidelity is the issue to be examined in this paper. Cyber-infidelity and cyber-affairs will be discussed both as potentially problematic behaviors evolving from women's involvement with technology, as well as the resulting issues raises for the feminist psychological community when considering treatment options, both "off and online." This paper, then will describe the behaviors associated with cyber-infidelity and the issues facing practitioners who attempt to ethically approach treatment in face-to-face or virtual environments.

Fueled by the Triple A engine of "accessibility, affordability, and anonymity" (Cooper, 1998) the Internet population seems to be exploring sexuality in ways that are unprecedented. As women build and tend relationships online, they are experimenting with discovering new sides of themselves, freed from many physical limitations and restrictive social roles. As they read the morning news, build networks of friends and family through email, and mount websites to advance their businesses and their personal missions, they are shaping as well as being shaped by the Internet.

Women are exploring new ways of interacting: they are engaging in email discussion lists, newsgroups, and websites that foster community building - and asserting themselves, initiating bold conversations, experimenting with anger and other previously unacceptable emotions, involving themselves in furtive love affairs, having cybersex within minutes of making an online acquaintance, and quickly ending liaisons that don't meet their needs. Women of all sizes, shapes, and complexions are attracting sexual attention from not only one partner, but also an unlimited number of individuals. Turkle believes we have only begun to see the types of changes in how people behave with new technology (1995). People are just learning to find what they seek, and some are struggling with how to make sense of what they find.

With romance and sexuality available to Internet users from the comfort and privacy of their homes and offices, it is not surprising the marital infidelity is also made more convenient to those seeking alternatives to their existing offline relationships. It is no small wonder that the electrical charge of love and romance can be heightened and intensified by the supercharged Internet. While the idea of sensual human electricity transmitted around the world is mind boggling, it is also intriguing, and often riveting.. When paired with anonymity, it can become a playground for the unconscious, for unexpressed desires, emotions, and needs.

Cyber-infidelity is defined as the act of engaging in acts of a romantic or sexual nature with an individual or individuals through electronic or virtual communities, i.e., as established through dating websites, email discussion lists, interactive games, chat rooms or newsgroups. Cyber-infidelity can easily lead to a cyber-affair, which involves the emotional investment of time and energy into an individual, group, or community

Empowered with the varied tools of the Internet, potential lovers are able to easily and inexpensively create any environment they desire in email or other text-based environments - a winter wonderland, steamy Chicago blues bar, or sweet and sweaty tropical paradise. They can experience the entire spectrum of a relationship online - from furtive glances across a chat room to wedding and divorce before their virtual friends and family. For those limited in real life by physical abilities, finances, or social skills, the Internet allows them to explore their inner drives with others who are admittedly doing the same.

For people who are in a committed and monogamous marriage offline, having an affair online can provide "extra romance" and "enriched" sexual experiences, but all too often, create the same threats to a committed relationship that exist in offline affairs (Turkle, 1997). Cyber-infidelity has already led to reports of family complications, strife, and divorce (Quittner, 1997; Shaw, 1997).

What then, is cyber-infidelity? As demonstrated by the Clinton scandal of 1998, even definitions of in-person sex are unclear, so remote infidelity as mediated by technology is yet more ambiguous. Semantic parsing aside, most Americans would probably agree that flirtation becomes infidelity when someone in a committed, monogamous relationship has erotic physical contact with someone other than his or her mate. Yet the throb of extra-marital attraction beats on - over the cyberwaves, with or without definition. The beginnings of cyber-affairs on the Internet can be compared to what happens over backyard fences, at local pubs, and in health clubs, and while not physical, certainly ban become very emotionally distracting from committed relationships offline. Attempts at definition range from those who claim there are different levels of infidelity, with live video interactions being more closely problematic than an email lover, to those who claim that having an affair, including cyber-sex, with an unseen lover doesn't count.

Essential questions appear more rapidly than their answers. Does propositioning someone online for cybersex count as emotional infidelity? If you enter a chat room, engage with a few people, and masturbate yourself to orgasm, are you cheating on your spouse? Does calling that person on the telephone and bringing each other to mutual orgasm count as infidelity? If not, what are you doing? Would you be comfortable seeking that answer when your Minister or Rabbi stops in for dinner this weekend? Technology is clearly escaping our ability to use traditional values to formulate answers, while dragging our hearts and souls behind.

On the other hand, you cannot legally prove adultery unless there is actual sex (Peterson & Miller, 1996, February 2). Nonetheless, many other questions remain. Has technology simply created an opportunity for those who do not have the courage to have a "real" affair? What percentage of people goes to the "next level"? What are the personality characteristics of those individuals who have cyber-affairs when compared to those who have offline affairs?

Obviously, an official definition of infidelity via cyberspace is not yet formulated. Nonetheless, there seems to be agreement that cyber-affairs are damaging to the core issues of trust and integrity in a relationship. Cyber-affairs involve fantasy, secrecy, preoccupation and a high sexual charge, paired with denial and rationalization (Leiblum, 1997; Shaw, 1997; Turkle, 1996). Each of these aspects of cyber-infidelity has implications for the feminist psychotherapist who brings traditional psychological understanding of relationship to the world of online romance. For example, the role of fantasy on the Internet has been discussed in many ways (Turkle, 1995). Schnarch believes (1997) that people avoid really knowing themselves or their partners when they substitute fantasy sex online for sex-in-the-flesh. When people accept responsibility for loving and being loved, they understand the power of completely exposing themselves to their loved one. When individuals have the courage to take that ultimate risk of exposure and still manage to receive a whole-hearted loving response from their partner, fantasy sex online only pales in comparison.

The question for psychotherapists examining and treating the problems associated with cyber-infidelity, is thus: how many women know true intimacy, practice it with their mate, and consider its ramifications when exploring the intriguing world of cyber-romance? How are women accepting or avoiding responsibility for their fantasy life in cyberspace? These questions have been broached by only a few theoreticians or researchers, and the information offered below will hopefully help to further elucidate some of these intriguing issues with particular attention to women.

Cyber-affairs can range from direct sexual encounters within minutes of meeting, to years of romance and courtship. Anything goes. It seems common that people online find it is a lot easier to ask and answer blatantly direct questions, without the fear that someone's jaw will drop, eyebrows will raise, or that they will be slapped. Consequences for asking deep personal questions and discussing deeply personal sexual practices are minimal on the Internet. There is minimal threat to physical safety, embarrassment, or public humiliation. Fantasy is often used to fill in the gaps and keep the activity focused on a variety of goals - from flirtation to orgasm.

Online foreplay can often be minimal. The very nature of some online environments are sexual, implying a moral tradition that makes it seem normal and thereby acceptable. Most dating and sex related areas announce their interest overtly. There are chat rooms for people who are "cheaters" or "married but sinful." Interested parties know exactly where to go and what do upon arrival. Early reports of difficulty with cyber-affairs come from people who have shared very personal details of their lives, including sexual preferences and problems, as well as those of their partners. An online "love" survey, conducted by iVillage (1999), reports that many people engage in such activities out of curiosity, for the experience of orgasm, or to relieve loneliness.

One thing is certain: suspicion of infidelity can seriously damage trust in relationship. Therefore, for our purposes, we'll use the word "infidelity" to describe the repeatedly taking of sexual energy outside of a committed, monogamous relationship through action intentionally leading to sexual arousal with an identified person, place, or thing. Secretive and deceptive behavior, denying suspicions when expressed by those who notice something amiss, and withdrawing emotional and sexual energy from their partner is common to both online and offline infidelity.

Whatever one chooses to call it, specific types of people engaging in cyber-affairs seem to be emerging. Several other surveys and discussion forums affiliated with SelfhelpMagazine.com have elicited numerous comments and submissions regarding the various types of cyber-affairs that appear to be common on the Net. While scientific research into this area is clearly needed to delineate a definitive typology, these observations are offered for discussion:

• Covert Cyber-affairs - this is the furtive, secret, and clandestine love affair communicated electronically rather than face-to-face;
• Overt Cyber-affairs - one partner in a relationship knows of the other's cyber-affair, but doesn't voice a desire for it to stop;
• Menage-a-Trois Cyber-affairs - couples engage with another specific person or persons in a cyber-affair;
• Group Cyber-affairs - people meet in a virtual community with the intent of having an erotic exchange.

Covert Cyber-affairs. Centuries of tradition have imbued routine affairs with expected levels of secrecy, motive, and result - with technology or without it. Technology has improved certain aspects, making it more convenient, more varied, and physically safer. But the seduction of satisfying one's sexual appetite with a few online nibbles before going for the real thing is simply a manifestation of people doing what they want to do, only doing it more easily with the tools of technology.

Overt Cyber-affairs. This type of affair can involve partners who either approve or disapprove of the affair. For couples who agree that one or both can participate in cyber-affairs, there are still many variations that can take place between a couple. Of course, there is always the subgroup of people that has come to accept a mate's affair because he or she sees no alternative after learning of the partner's cyber-affair….

• With Partner Approval: For those who are in a committed and monogamous marriage offline, having an affair online can provide extra romance and enriched sexual experiences, reportedly without endangering a marriage (Turkle, 1997).
• Without Partner Approval: When the affair continues without partner approval, it can wreak havoc in a relationship, and has already led to many divorces (Leiblum, 1997; Shaw, 1997).

Menage a Trois. For those who share their messages with their spouses, when the activities are performed with the partner's approval or participation, there can even be added stimulation in their offline lovemaking. For these people, the exchanges are reportedly considered a "turn on" for the spouse of the person having the affair. For them, it is added fuel for sexual contact with their offline and, sometimes, online partners. The long-term effects of these experiments upon the stability of committed offline relationships have not yet been examined, however. Leiblum mentions the existence but relative infrequency of such arrangements (Leiblum, 1997).

Covert Group Cyber-affairs - The Lurker. This group is on the fringe of the infidelity camp, perhaps developing a predilection for one particular virtual community, or one type of virtual community (S&M, or simply one particular dating site). This member's object of desire, then, might be to participate in the community itself, or follow the behavior of specific members of the community. Some of these members might be :lurkers," who participate passively. In what might be considered "cyber-voyeurism," they might watch the exchanges of other people, and never make their presence known. Voyeurism is easily enabled by technology and culminates in anonymous servers posting to anonymous websites where anything goes.

What of the individual who lurks because of extreme shyness, loneliness, and/or desperation, working up the courage to venture forth occasionally and finding that no one responds? Lurkers might be likely to leave a forum first when discomfort arises, taking feelings with them that might be their own painful fabrications, just as others may leave with emotions that are their romanticized fabrications. Research is clearly needed to identify the characteristics of this group in particular. The lurker might be the most fascinating type of individual to study over the next decade, simply because their very existence is predicated on technology that makes them invisible to those being watched.

These individuals are likely to seek sexual arousal or masturbate upon recognizing one of their favorite people actively participating in group cybersex, or following discussions about stimulating topics. Whether this type of cyber-infidelity meets the criteria of infidelity in the traditional sense of the word, or is on par with reading pornographic magazines is to be debated. Certainly, factors such as repeated exposure, allegiance to one group versus another, attempts to seek contact with group members outside of the group, pre-occupation with the group experience when interacting with one's real face-to-face partner, and frequency of engagement with the group are all elements that will enter into the debate.

Just as research is needed to delineate various types of behaviors that can be expected by psychologists when treating individuals who struggle with disorders related to the Internet (Young, 1997, 1998a, 1998b, 1999), psychologists need to concern themselves with understanding and developing treatment strategies for patients whose cyber-infidelities lead to unexpected strife. Early sex theorists are already speculating on these issues.

Damage to the Self. Several early theorists are observing that, just as with offline affairs, integrity and self-esteem are also vulnerable to cyber-affairs. How does someone live with oneself when accepting a carefully prepared meal with one hand, while hiding a steamy, graphic description of sexual fantasy fulfilled by a few clicks of the mouse on the other hand? While some people may not experience guilt over such inconsistency in behavior, many will. They may not understand it, but it may damage their intimacy the next time they try to feel connected to their spouse or partner. It may weigh on them, costing them valuable emotional energy, which could otherwise be available for deepening a face-to-face relationship that has grown stale. Affairs are a betrayal of the self. Shaw states, "Internet infidelity might indicate that an individual is developed enough emotionally to find a partner but not developed enough to be openly, compassionately oneself in relationship with that partner" (1997, p. 30-31).

Deception. Deception is generally recognized as one of the most destructive elements of infidelity. When discussing deception in cyber-affairs, the Vaughans (1996) conclude, "In fact, most people whose partners have a sexual affair find that they recover from the fact that their partner had sex with someone else before they recover from the fact that they were deceived".

Lies of omission related to an affair are violations of monogamy. The difficulty with deception related to any type of affair is that it typically creates emotional distance and ultimately severs trust, the cornerstone of all agreements. "This is not the same as reading Playboy," said Sherry Turkle as quoted in Time by Toufexis, "There really is another person there, and that person can touch you and move you in various ways, emotionally and sexually" (1996, p. 53).

Proximity as Heightened Betrayal. One feature of these relationships heightening a partner's sense of betrayal is that access to another love interest can literally occur from one's own living room, den, or even family room - without the knowledge of partner whose trust is being violated. Some people not only report outrage that infidelity was happening right in their own homes, under their very noses, but that they were naïve enough to be bringing meals, refreshments, or other services to the offending partner at the computer.

While such behavior is often experienced by the faithful partner as a new peak of betrayal and callousness, the proximity of access to an online lover is often reported as heightening arousal in those who are having the affair. The ease with which naughty behaviors can happen in one's home or office may add intrigue and titillation for some people who pursue these activities, but may heighten the sense of mistrust once the betrayal has been revealed to the faithful partner.

Albeit self-report and field research, the slowly growing body of literature regarding gender differences on the Internet is suggesting differences between men and women. A tendency for women toward seeking relationship is suggested by the MSNBC study, completed during March and April of 1998 at the MSNBC website (Cooper, Scherer, Boise & Gordon, 1999). Women favored sexual chat rooms more than twice a much as men (49% vs. 23%), while men preferred Web sites featuring visual erotica more than twice a much as women (50% vs. 23%).

The SHPM Cyber-affair Survey (Maheu, 1999a), conducted since 1996 at SelfhelpMagazine.com, indicates that almost half of the respondents believe that those engaging in cyber-affairs are also engaging in "real sex." These findings are in accordance with the behaviors commonly observed in many dating websites, for example. Sexuality in the form of arousing exchange culminating in self-masturbation is common. Cyber-infidelity, then is often not simply the exchange of romantic correspondence, but rather, often involves direct sexuality.

Furthermore, 66% of the SHPM survey respondents claimed to be in favor of cyber-affairs, yet 70% thought cyber-affairs pose a threat to traditional relationships.

These findings are worthy of note. While they indicate values that are held by a significant majority of respondents, the group is self-selected, and may be biased. However, these items point to values that can be considered contradictory to traditional marital relationships. Since the sample was 64% female, these trends may be reflective of the changing values of women on the Internet. It is clear that social research in this area is warranted to elucidate the possibility that given the new-found freedoms of invisibility and anonymity offered by technology, women are choosing to behave in ways that are contradictory to their own beliefs.

Where will technology allow us to go? How will our definitions of monogamy change as a result? As scientists, we have not only to keep an eye on what is happening today, but given the rapid proliferation of technology and its ever-reaching capabilities, we also need to be mindful of future trends when examining its impact upon relationships and fidelity.

The Future of Cyber-infidelity and Hepatics. Hepatics is the science of transmitting a sense of touch with the purpose of creating a real experience in the virtual world. The future will bring the use of full-immersion sex suits, transmitting sensory information back and forth between partners. And because the exchange will simply be digitized information, it too will be modifiable, in essence, "tailored" to the user's discretion to reflect preferences and other specially desired effects (Dertouzos, 1997). Participants might, for example, make themselves a different weight, height, attractiveness, gender, or conceivably even add extra limbs or appendages to their bodies. The possibilities are endless. Examples of such tailoring might include: young woman pretends to be a man with an erection, an elderly person pretends to be a virgin teenager, or a doctor pretends to be a macho construction worker with five muscled arms.

Thus equipped with pressure and movement sensitive bodysuits, augmented with large screen monitors or high tech goggles, our next generation of "wired" individuals can be virtually sexual in new and very powerful ways. This kind of virtual sex is not likely to replace "fleshmeet" but will most certainly augment it. Discussing the primal draw of face-to-face contact, Dertouzos offers a theory for its continued appeal:

"We know that if the long-distance relationships of pen pals are not nourished by some form of physical closeness, they will wither…. Most of us think we're unique and in control of our behavior. Yet we carry the features and mannerisms of our ancestors as well as our common reflexes and human patterns acquired through evolution. The fear, love, anger, greed, and sadness that we feel today are rooted in the caves that we inhabited thousands of years ago. It was in the ancient setting that the predator's growl and the enemy's attack defined primal fear. It was there, too, that our other primal feelings became reinforced - protecting our children, enjoying the pleasure of physical contact with our mate, relying on our fellow tribes people, and so on. These are the forces of the cave. And they haven't left us….Yet, the fact of the matter is that these forces are probably the most important forces of our lives; they are the magical forces that bind parents and children, healers and patients, close associates, siblings, spouses, lovers, good friends… and bitter enemies" Dertouzos, 1997, p. 300

The future will increasingly allow users to see and hear their virtual sex partner as if they are in the same room, while also offering the possibility of interacting with this partner through imaginary identities. Sexual gamers will take on added capabilities, with combinations of experiences simulated by the technology for the individual interested in static masturbation as well as with interactive playmates. The world of cyber-infidelity is just beginning, and we as psychotherapists must not only be aware of it, but also must be prepared for problems that will arise because of it. With these formative factors unleashed through the Internet, how will we develop appropriate treatment protocols and interventions for Internet-distressed women and their relationships?

How are professionals to address issues such as cyber-infidelity? Two scenarios are now possible: face-to-face and through telEhealth equipment. Since most psychotherapists are familiar with face-to-face interventions, only a brief outline of relevant cyber-infidelity topics will be discussed below. Since many psychotherapists are starting to wonder how services might be offered through telEhealth equipment, and the Internet in particular, information related to the ethics of offering psychotherapy via email will also be outlined below. For information regarding how to offer psychotherapy using videoconferencing equipment, see Maheu (1999b).

Face-to-face Psychotherapeutic Issues for Cyber-infidelity. In general, the therapist working with a patient seeking treatment for issues related to cyber-infidelity would do well to help the patient clarify current domestic partner arrangements and agreements, as well as the advantages and disadvantages of proceeding with self-gratification via the Internet. In doing so, a thorough history of all infidelity-related behaviors would be in order. More specifically, a thorough inventory of all Internet-based cyber-infidelity behaviors might be examined. For example, various types of services used, frequency, duration, screen names, personalities portrayed, types of partners of interest online, drug/alcohol use, paraphilias experienced, and self-imposed limits by patients ought to be explored by the clinician. Overall, clinicians would also do well to learn the details of their patient's interactive style if they present such issues in treatment. Current state of face-to-face, monogamous relationship is also critical to understanding the appeal of the Internet world. Clinical inquiry may uncover other aspects of romance and sexuality related to personality style, and give valuable clues to psychotherapists as well as researchers, who have a new arena within which to examine personality structure, commitment and sexuality.

As with more generalized Internet compulsions, cyber-infidelity may be part of both the problem and the solution. Individuals suffering from the effects of cyber-infidelity may soon be approaching psychologists for help with cyber-infidelity. They may conceivably approach psychologists through either the Internet and request email consultation, telephone consultation, videophone or other videoconferencing consultation, as well as, or in addition to traditional face-to-face consultation (Maheu & Gordon, in preparation).

Treatment of Cyber-infidelity issues in Email. Some of the more serious ethical questions arise when patients want to obtain treatment in email. Until broadband services are available through the Internet2 (Next Generation Internet Initiative, 1999; University Corporation for Advanced Internet Development, 1999), therapists face a number of challenges when attempting to comply with the ethics code, and deliver psychotherapy through the Internet (Maheu, 1996, 1997a, 1997b, 1998a, 1998b).

For the sake of brevity, only a sample of the key treatment issues are discussed here, but the reader is referred to the following documents for more general guidelines regarding ethics (APA, 1985, 1986, 1992, 1993a, 1993b, 1997a). For the precise wording of each principle discussed below, see the American Psychological Association's Ethical Principles of Psychotherapist and Code of Conduct (1992). Numbers and titles of principles are provided for your convenience.

This paper examines only selected standards among those identified as relevant by the American Psychological Association Ethics Committee's document entitled Services by Telephone, Teleconferencing, and Internet (APA, 1997b). Questions and issues are noted after each of the ethics standards numbered and titled for the reader's convenience, and are preliminary questions offered as a sample of the types of challenges we might face with regard to ethics when delivering psychotherapy over the existing form of the Internet.

1.03 Professional and Scientific Relationship. If delivering services via the existing Internet, precisely how will we define a "professional relationship" between a psychologist and patient struggling with cyber-infidelity? For example, what if the patient contracts for education, but regularly sends email questions - how many email posts will it take before the relationship moves from educational to psychotherapeutic? Or once Internet2 is in place, with it's capacity for two-way videoconferencing, will a single web-based video session legitimately constitute education, but several sessions psychotherapy? How will third party carriers differentiate which services will be reimbursable and which won't?

What if a patient contracts for education, but writes regularly and wants to include their spouse or cyber-lover in the therapy? Is that legitimate use of psychotherapy and technology? Surely, these questions only scratch the surface of the types of professional issues to be raised by telEhealth tools, and email exchanges in particular, in the next five to ten years.

1.04 Boundaries of Competence. How much training should be required for psychotherapy with cyber-infidels, their cyber-lovers and/or spouses over the Internet? Who will offer this training? A second issue is one whether we are subjecting our patients to harm if we are just learning how to use technology and/or have never met the patient face-to-face prior to meeting via technology. Who is to say that face-to-face visits are required, ever? If they are, how many prior or concurrent face-to-face meetings will legitimize later email services?

Internet connections literally span the globe. Other complicated issues include the need to respect cultural diversity in a medium where geographic distance is rendered irrelevant. Without full disclosure by the patient, or testing of the patient, the professional could easily be uninformed of critical socioeconomic issues, educational, cultural or geographic issues that could influence the response set of the patient. For example, how much assessment through websites is responsible vs. feasible? Which instruments are to be used, when most standard assessment instruments haven't been normed on an international web-based populations? How honest will patients be in answering web-based forms when seeking email or video contact from a professional?

Which instruments should be used with women in particular? More specifically, what ought a therapist know of a woman making contact through a website and requesting assistance for a cyber-affair? How can the therapist best discover facts such as local events - such as family events, or other situational events assumed to be irrelevant to the patient, but nonetheless, potentially important to the therapy? For example, how will the psychotherapist know of natural disasters, family deaths, or emergency backup services in the patient's community when responding to a website request for email, chatroom, or videophone intervention for a cyber-affair?

Moreover, could the issue of competence as a telEhealth professional be related to the choice of technology? How proficient at various technologies ought a practitioner be before offering professional services to consumers claiming to suffer from a cyber-affair in email, chat rooms, IRCs, MOOs, or MUDS? How many practitioners even know what these technologies are, and what they are capable of creating for the patient? If using an interpreter in any of these modalities, how would the professional be assured of competence in dealing with an interpreter?

Transference and countertransference will undoubtedly find new forms of expression. In treating disorders related to cyber-infidelity, how might a practitioner delivering email treatment for cyber-infidelity know if interactive discussion about a patient's specific problem is serving more as active sexual stimuli than as treatment? Upon learning that previous treatment has been misused in this way, what does the practitioner do? Terminate? Would the practitioner then be liable for abandonment? If termination isn't acceptable, would might proper procedure dictate? Will videoconferencing be an accepted alternative treatment vehicle? If yes, under which circumstances will it acceptable or unacceptable?

1.06 Basis for Scientific and Professional Judgments: Given the lack of scientific knowledge in the area of using advanced technology the Internet to deliver assessment and treatment, are website disclaimers adequate to limit misunderstanding related to services being offered? Although some practitioners have already begun using disclaimers to qualify their services, the rigors of research have not yet been applied to test the effectiveness of these disclaimers.

Furthermore, research is just beginning to appear regarding the effectiveness of various forms of media, including email, audio-stream, and video-mediated communication (O'Conaill & Whitaker, 1977; Whittaker & O'Connaill, 1977). Nonetheless, research is beginning to reflect the benefits of these types of services in dealing with the treatment of women in general, and cyber-infidelity in particular (Cooper, 1998; Shaw, 1997).

1.07a Describing the Nature and Results of Psychological Services. When dealing with "informed consent, " just how informed of risks and benefits will our patients be when it comes to treatment through technology, when many us barely know, or want to know the inner workings of the human mind as mediated through technology? For example, issues such as the reading level of the unseen email-based patient are critical if we are to provide interventions in a manner understandable to the patient, as dictated by this ethical principle. The professional may be at a loss for how to best correct a miscommunication if the unseen, unheard patient cannot be relied upon to understand a web-based consent from, email interpretations or assignments given.

Moreover, the necessity for gathering demographic data, such as telephone number and street address, or how to best inform the of mandated reporting laws consumer are still undefined when the consumer is "simply asking a question about a cyber-affair." Problems with this ethics principle become particularly apparent if someone were to reveal the details of abuse or a Tarasoff situation prior to any type of response from the psychologist.

1.14 Avoiding Harm: While the overall focus of the ethical principles is to protect consumer welfare, this principle is more precisely focused upon specific ways in which harm can and needs to be avoided by the professional. Several key concerns arise in treating any mental health issue in a technology-based environment. For example, the ease of impersonation facilitated by email exchange may create specific dilemmas for a well-intentioned therapist. Especially in the online sexual arena, where impersonation, exaggeration and minimization are commonplace, problems may arise for the unwitting therapist. For example, if engaging a teenager pretending to be an adult struggling with a cyber-affair, how much liability does a practitioner assume for giving explicit information? The central factor related to this principle is that in text-based environments, i.e., email or chat rooms, the psychologist lacks the visual and auditory cues used in professional training and supervision to diagnose and treat patients.

Other issues must also be considered. For example, time differences in the formulation and delivery of email may also cause discrepancies in the understanding of the professional, as well as the patient. The frequency of equipment failure in various electronic media, including email, chat rooms, and video connections can further complicate the relationship between practitioner and patient.

Moreover, email contact with patients may make psychologists vulnerable to formal complaints, if the email exchange is taken out of context, or used as a verbatim record of services rendered. This problem surfaces most clearly in situations related to emergencies, for example. Since email and video-mediated services can occur wherever phone lines reach people, a practitioner in Boise may easily be working with a patient in Boston. How obligated is the practitioner to know and communicate state laws to the Boston resident? Reporting laws related to child abuse, for example, vary from state to state, and a practitioner is not likely to be aware of ramifications of specific instructions given to patients in email.

Some state laws prohibit practice out of state for professionals operating in specific environments. For example, in California, practitioners are prohibited from offering video-mediated service to out-of-state patients, but can communicate in email without sanctions (CA-1997). Details of telEhealth laws in various states are available (Center for Telemedicine Law, 1997; Department of Commerce, 1997). Some professions have developed their own viewpoints regarding interstate licensure and confidentiality (National Council of State Boards of Nursing, 1998). More precise definitions of psychotherapy will be needed if such exchanges start occurring with regularity in psychology, and particularly in the treatment of problems associated with a cyber-affair as treated through telEhealth technologies.

Nonetheless, professionals in the health community are already successfully using regular email contact with patients (Borowitz & Wyatt, 1998; Eysenbach & Diepgen, 1998; Ferguson, 1998; Spielberg, 1998). The simple truth is that electronic media may prove to be more helpful than face-to-face contact for some people. Indeed, refusing email contact from an otherwise isolated and desperate patient suffering from a cyber-affair, for example, could lead be harmful to the patient requesting help, as well as potential victims. So the question becomes: precisely what is our obligation to respond to such queries for assistance?

2.01 Evaluation, Diagnosis, and Interventions. Computer-mediated communication technologies already has an extensive literature (Booth-Kewley, Edwards & Rosenfeld, 1992; Browndyke, 1996; Browndyke, Santa Maria, Pinkston & Gouvier,1998; Burke & Normand, 1987; Dubrovsky, Kiesler & Sethna, 1991; Fawcett & Buhle, 1995; Federico, 1992; Gaydosh 1996; George, Lankford & Wilson 1992; Gressard & Loyd, 1986; Hewson, Laurent & Vogel, 1996; Honaker,1988; Johnson & White, 1980; Kieley, 1996; Kiesler & Sproull, 1986; King, 1996; Koson, Kitchen, Kochen & Stodolosky, 1970; Liefeld, 1988; Makulowich, 1995; Mazzeo & Harvey, 1988; Mead & Drasgow, 1993; Mehta & Sivadas 1995; Moreland,1985; Sampson, 1983; Sampson, Kolodinsky & Greeno,1997; Skinner & Allen, 1983; Smith & Leigh, 1996; Space, 1981; Sproull, 1986; Stern & Faber, 1996; Thomas, 1996; Walsh, Kiesler, Sproull, & Hesse; 1992; Waskul & Douglass,1996; Webster & Compeau, 1996). While guidelines are provided for practitioners in several APA documents related to computer-based tests and interpretations (1986) and standards for educational and psychological testing (1985), more guidance is needed for applying these principles to behavioral telEhealth, and more specifically, for applying these guidelines to the treatment of cyber-affairs. Another area needing focused attention is that of how technology impacts communication (Cukor et. al., 1998; O'Conaill & Whittaker, 1997; Whittaker & O'Conaill, 1997).

5.02 Maintaining Confidentiality. While various aspects of the Internet are secured for some purposes, much of it is quite vulnerable to breaches of confidentiality.

One of the most pressing issues needing examination is that related to the electronic patient record. Centralized electronic medical records are being developed into a single, multi-user database in the United States (Computer-based Patient Record Institute, 1999). Theoreticians and researchers in both psychology (Maheu, 1996, 1998d; Maheu, Whitten & Allen, in press; Maheu, Callan & Nagy, in press; Nickelson, 1998b; Stamm, 1998) and medicine (Carroll, Wright & Zakoworotny, 1998; Spielberg, 1998; Waller & Alcantara, 1998) as well as professionals from other countries (Mitka, 1998) are discussing the protection of patient information.

Meanwhile, laws are being developed that will also define the future of telEhealth and confidentiality. On August 1, 1996, the Health Insurance Portability and Accountability Act (Public Law 104-191), otherwise known as the Kennedy-Kassenbaum Act, was introduced in Congress. The Health Insurance Portability and Accountability Act (HIPAA) called for protections for the privacy of medical information. It is an attempt to improve the portability and continuity of health insurance coverage through administrative simplification by the Congress and the Department of Health and Human Services (DHHS).

HIPAA includes provisions to address the need for security and electronic signature standards. These standards will reduce unauthorized access and alteration of confidential health records by implementing universal security, integrity, and authentication standards, and will be enforced through harsh penalties for those responsible for their violation. The standards will apply to all electronic health data transmitted by health care providers, health care clearinghouses, health plans, that is in transit, or, resides in a practitioner's data system, or in other information depositories (Gilbert, 1999). Compliance with this law will be required by February 2002.

Meanwhile, input is being sought by various governmental agencies to aid with applicability and compliance to this law. Therefore, psychologists have an opportunity to shape the development of broad-sweeping and precedent-setting legislation if they get involved immediately. The content and electronic transmission of mental health records should be defined by psychologists, and not other professional groups, or by insurance companies. Patients should also be given a voice in determining the fate of their medical records (Maheu, 1997b, 1998c).

In conclusion, for many ethical reasons, email interventions are inefficient for psychotherapy when used in the absence of other treatment modalities, i.e., face-to-face, and videoconferencing. Alternatives are quickly appearing, however. Videoconferencing allows us to use the visual and auditory cues we are trained to use in diagnosing and treating patients, and therefore, is a more adequate technology to use when delivering psychotherapy. Newer technologies and increased experimentation with these electronic tools will undoubtedly show which telEhealth technologies are best used with which patients, at which point in time, and by which practitioners.

As the Global Community proliferates, it provides us with arena for creating new problems as well as providing new solutions. Trained as social scientists and practitioners, psychologists are in an optimal position to both study these evolving behaviors, and develop effective treatment protocols in both the face-to-face and electronic worlds.

REFERENCES

American Psychological Association. (1985). Standards for educational and psychological testing. Prepared by the Committee to Develop Standards for Educational and Psychological Testing of the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education. Washington D.C.: American Psychological Association.

American Psychological Association. (1986). Guidelines for computer based tests and interpretations. Washington, D.C.: American Psychological Association.

American Psychological Association. (1992). Ethical principals of psychologists and code of conduct.American Psychologist, 47 (12), 1597-1611.

American Psychological Association. (1993a). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48 (1), 45-48.

American Psychological Association. (1993b). Record keeping guidelines. American Psychologist, 48(9), 984-986.

American Psychological Association. (1997a). Official home page of the American Psychological Association. Retrieved January 8, 1999 from the World Wide Web: http://www.apa.org

American Psychological Association. (1997b). Services by telephone, teleconferencing, and Internet. [A statement by the ethics committee of the American Psychological Association]. Retrieved November 18, 1998 from the World Wide Web: http://www.apa.org/ethics/stmnt01.html

Booth-Kewley, S., Edwards, J.E., & Rosenfeld, P. (1992). Impression management, social desirability, and computer administration of attitude questionnaires: Does the computer make a difference? Journal of Applied Psychology, 77, 562-566.

Borowitz, S. M. & Wyatt, J. C. (1998). The origin, content, and workload of E-mail consultations. The Journal of the American Medical Association, 280(15), 1321-1324.

Browndyke, J.N. (1996). Online Neuropsychology Project. Retrieved July 13, 1996 from the World Wide Web: http://www.premier.net/~cogito/project/onp.html

Browndyke, J.N, Santa Maria, M.P., Pinkston, J.B., & Gouvier, W.D. (1998). Online neuropsychology project: A survey of general head injury and prevention knowledge between professionals and non-professionals. Archives of Clinical Neuropsychology, 13(1), 133.

Burke, M.J., & Normand, J. (1987). Computerized psychological testing: Overview and critique. Professional Psychology: Research and Practice, 18, 42-51.

Carroll, E. T., Wright, S., & Zakoworotny, C. (1998 ). Securely implementing remote access within health information management. Journal of American Health Information Management Association, 69(3), 46-49.

Center for Telemedicine Law. (1997). Telemedicine and interstate licensure: Findings and recommendations of the CTL licensure task force. North Dakota Law Review, 73(1), 109-130.

Computer-based Patient Record Institute. (1999). CPRI Toolkit: Managing information security in health care. Bethesda, MD: Author.

Cooper, A. (1998). Sexuality and the Internet: Surfing into the new millennium. Cyberpsychology and Behavior, 1, 181-187.

Cooper, A., Scherer, C., Boise, S. & Gordon, B. (1999). Sexuality on the Internet: From sexual exploration to pathological expression. Professional Psychology: Research and Practice, 30 (2), 154-164. Retrieved August 15, 1999 from the World Wide Web: http://www.apa.org/journals/pro/pro302154.html

Cukor P., Baer L., Willis B.S., Leahy L, O'Laughlen J., Murphy M.E., Withers M., and Martin, E. (1998). Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemedicine Journal, 4(4) 313-21.

Department of Commerce. (1997). Telemedicine Report to Congress. Retrieved January 8, 1999 from the World Wide Web: http://www.ntia.doc.gov

Dertouzos, M. (1997). What will be: how the new world of information will change our lives( pp. 300). New York: HarperCollins.

Dubrovsky, V.J., Kiesler, S., & Sethna, B.N. (1991). The equalization phenomenon: Status effects in computer-mediated and face-to-face decision-making groups. Human Computer Interaction, 6, 119-146.

Eysenbach, G., & Diepgen, T. L. (1998). Responses to unsolicited patient email requests for medical advice on the World Wide Web. The Journal of the American Medical Association, 280, 1333-1335.

Fawcett, J., & Buhle, E. (1995). Using the Internet for data-collection: An innovative electronic strategy. Computers in Nursing, 13(6), 273-9.

Federico, P. (1992). Assessing semantic knowledge using computer-based and paper-based media. Computers in Human Behavior, 8, 169-181.

Ferguson, T. (1998). Digital Doctoring - Opportunities and Challenges in Electronic Patient-Physician Communication, The Journal of the American Medical Association. 280, 1361-1362.

Gaydosh, C.N. (1996). Using the internet for triple-blind psychological research studies. Paper presented at the 1996 Society for Computers in Psychology Conference. Chicago, IL.

George, C.E., Lankford, J.S., & Wilson, S.E. (1992). The effects of computerized versus paper-and-pencil administration on measures of negative affect. Computers in Human Behavior, 8, 203-209.

Gilbert, F. (1999). HIPAA and the Electronic Record. Comprehensive Guide to Electronic Health Records. Washington, DC: Author.

Gressard, C.P, & Loyd, B.H. (1986). The nature and correlates of computer anxiety in college students. Journal of Human Behavior & Learning, 3, 28-33.

Hewson, C.M., Laurent, D., & Vogel, C.M.(1996). Proper methodologies for psychological and sociological studies conducted via the internet. Behavior Research Methods, Instruments, and Computers, 28, 186-191.

Honaker, L.M. (1988). The equivalency of computerized and conventional MMPI administration: A critical review. Clinical Psychology Review, 8, 561-577.

Johnson, D.F., & White, C.B. (1980). Effects of training on computerized test performance in the elderly. Journal of Applied Psychology, 65, 357-358.

Kieley, J.M. (1996). CGI scripts: Gateways to world-wide-web power. Behavior Research Methods, Instruments, and Computers, 28, 165-169.

Kiesler, S., & Sproull L.S. (1986). Response effects in the electronic survey. Public Opinion Quarterly, 50, 402-413.

King, S. (1996). Researching Internet communities: Proposed ethical guidelines for the reporting of results. The Information Society, 12(2).

Koson, D. Kitchen, C. Kochen, M. & Stodolosky, D. (1970). Psychological testing by computer: Effect on response bias. Educational & Psychological Measurement, 30, 803-810.

Leiblum, S. (1997). Sex and the Net: Clinical implications. Journal of Sex Education and Therapy, 22(1), 23.

Liefeld, J.P. (1988). Response effects in computer-administered questioning. Journal of Marketing Research, 25, 405-409.

Maheu, M. & Gordon, B. (in preparation). Survey of mental health practitioners on the Internet. Professional Psychology: Research and Practice.

Maheu, M. (1996, August). Online ethics and risk management. Symposium conducted at the Albert Einstein School of Medicine Department of Psychiatry, 17^th Cape Cod Institute.

Maheu, M. (1997a, April). Ethics of Online Psychology. Symposium conducted at the California Psychological Association, San Jose, California.

Maheu, M. (1997b). Will online services for consumer self-help improve behavioral healthcare? Behavioral Healthcare Tomorrow Journal. 6(6), San Francisco: Centralink.

Maheu, M. (1998a, March).Issues and Opportunities in Behavioral TelEhealth. Symposium conducted at the meeting of the California Psychological Association, Pasadena, California.

Maheu, M. (1998b, March).Ethics of Practicing Psychology Online. Symposium conducted at the meeting of the California Psychological Association, Pasadena, California.

Maheu, M. (1998c, March). How online & other telEhealth services for consumers & their families impact behavioral healthcare. Symposium conducted at the meeting of the Behavioral Informatics Tomorrow, San Antonio, Texas.

Maheu, M. (1998d). TelEhealth - A call to action. American Association of Behavior Therapists. The Behavior Therapist, 21, (6).

Maheu, M. (1999a). SHPM cyber-affairs survey results. Retrieved from the World Wide Web Thursday, August 12, 1999. http://www.selfhelpmagazine.com/cgibin/cyber_survey.cgi?results=go&start=go

Maheu, M. (1999b). Risk management in the re-tooling of healthcare. Retrieved from the World Wide Web Thursday, August 12, 1999. http://telehealth.net/articles/riskman3.html

Maheu, M., Callan, J., & Nagy, T. (in press). Call to Action: Ethical and legal issues for behavioral telEhealth including online psychological services. In S. Bucky (Ed.), Comprehensive Textbook of Ethics and Law on the Practice of Psychology. New York: Plenum Publishers.

Maheu, M., Whitten, P. & Allen, A. (in preparation). The telEhealth primer & resource guide. New York: Jossey-Bass.

Makulowich, J.S. (1995). Labs online: research on the Internet. Environmental Health Perspectives, 103(2), 148-50.

Mazzeo, J. & Harvey, A.L. (1988). The equivalence of scores from automated and conventional educational and psychological tests: A review of the literature (College Board Rep. No. 88-8).

Mitka, M. (1998 ). Developing countries find telemedicine forges links to more care and research. The Journal of the American Medical Association, 280(15), 1295-1296.

Mead, A.D., & Drasgow, F. (1993). Equivalence of computerized and paper-and-pencil cognitive ability test: A meta-analysis. Psychological Bulletin, 114, 449-458.

Mehta, R., & Sivadas, E. (1995). Comparing response rates and response content in mail versus electronic mail surveys. Journal of the Market Research Society, 37, 429-439.

Moreland, K. L. (1985). Computer-assisted psychological assessment in 1986: A practical guide. Special Issue: Computer assessment and interpretation: Prospects, promise and pitfalls. Computers in Human Behavior, 1, 221-233.

National Council of State Boards of Nursing. (1998, April). Boards of nursing approve proposed language for an interstate compact for a mutual recognition model for nursing regulation. Communique, 1-4.

Next Generation Internet Initiative. (1999). Retrieved March 4, 1999 from the World Wide Web: http://www.ngi.gov.

Nickelson, D. (1998b). TelEhealth and the Evolving Health Care System: Strategic Opportunities for Professional Psychology. Professional Psychology: Research and Practice, 29X(6), 527-535.

NUA. (1998). How many online? New York: NUA Ltd. Retrieved August 16, 1999 from the World Wide Web: http://www.nua.ie/surveys/how_many_online/index.html

O'Conaill, B., & Whittaker, S. (1997). Characterizing, predicting, and measuring video-mediated communication: A conversational approach. In K. E. Finn, A. J. Sellen, & S. B. Wilbur (Eds.), Video-Mediated communication (pp. 107-131). Mahwah, NJ: Lawrence Erlbaum.

Payment for Teleconsultations in Rural Health Professional Shortage Areas, 63 Fed. Reg. 58879 (1998).

Peterson, K. & Miller, L. (1996, February 2). On-line adultery: Cyberflings are heating up the Internet. USA TODAY, pp 01D.

Quittner, J. (1997, April 14). Divorce Internet Style. Time, p. 72.

Sampson, J.P. (1983). Computer-assisted testing and assessment: Current status and implications for the future. Measurement & Evaluation in Guidance, 15, 293-299.

Sampson, J., Kolodinsky, R., & Greeno, B. (1997). Counseling on the information highway: Future possibilities and potential problems. Journal of Counseling and Development, 75(3), 203-212.

Shaw, J. (1997). Treatment rationale for Internet infidelity. Journal of Sex Education & Therapy, 22 (1), 29-34.

Skinner, H.A. & Allen, B.A. (1983). Does the computer make a difference? Computerized versus face-to-face versus self-report assessment of alcohol, drug, and tobacco use. Journal of Consulting & Clinical Psychology, 51, 267-275.

Smith. M.A. & Leigh, B. (1996). Using the world wide web to institute a distributed, on-line participant pool. Paper presented at the 1996 Society for Computers in Psychology Conference. Chicago, IL.

Schnarch, D. (1997). Sex, intimacy, and the internet. Journal of Sex Education and Therapy, 22(1), 15-20.

Space, L.G. (1981). The computer as psychometrician. Behavior Research Methods and Instrumentation, 13, 595-606.

Spielberg, A. R. (1998). On call and online: Sociohistorical, legal, and ethical implications of email for the patient-physician relationship. The Journal of the American Medical Association, 280, 1353-1359.

Sproull, L.S. (1986). Using electronic mail for data collection in organizational research. Academy of Management Journal, 29,159-169.

Stamm, B., (1998). Clinical Applications of TelEhealth in Mental Health Care. Professional Psychology: Research and Practice, 29, (6), 536-542.

Stern, S.E. & Faber, J.E. (1996). The lost email method: Milgram's lost letter technique in the age of the internet. Paper presented at the 1996 Society for Computers in Psychology Conference. Chicago, IL.

Thomas, J. (Ed.). (1996). The Ethics of Cyberspace Research [Special Issue]. The Information Society, 12(2).

Turkle, S. (1997). Life on the screen: Identity in the age of the internet. New York: Touchstone.

Turkle, S. Quoted in: Toufexis, A. (1996, February 19). Behavior: Romancing the computer. The first cyberadultry suit shows the risks of looking for love online. Time, p. 53.

University Corporation for Advanced Internet Development. (1999). Retrieved March 4, 1999 from the World Wide Web: http://www.ucaid.edu/

Vaughan, J. & Vaughan, P. (1996) Online affairs. Retrieved May 15, 1998 from the World Wide Web: http://www.vaughan-vaughan.com/com010.html

Walsh, J.P., Kiesler, S., Sproull, L.S., & Hesse, B.W. (1992). Self-selected and randomly selected respondents in a computer network survey. Public Opinion Quarterly, 56, 241-244.

Waller, A., & Alcantara, O. (1998). Ownership of health information in the information age. Journal of American Health Information Management Association, 69(3), 28-38.

Webster, J., & Compeau, D. (1996). Computer-assisted versus paper-and-pencil administration of questionnaires. Behavior Research Methods, Instruments, & Computers, 28, 567-576.

Whittaker, S. & O'Conaill, B. (1997). The role of vision in face-to-face and mediated communication. In K. E. Finn, A. J. Sellen, & S. B. Wilbur (Eds.), Video-mediated communication (pp. 23-49). Mahwah, NJ: Lawrence Earlbaum.

Young, K. S. (1997). The relationship between depression and Internet addiction. Cyberpsychology and Behavior, 1(1), 24-28.

Young, K. S. (1998a) Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1(3), 237-244.

Young, K. S. (1998b). Caught in the Net: How to recognize the signs of Internet addiction and a winning strategy for recovery. New York, NY: John Wiley & Sons, Inc.

Young, K. S. (1999) The Evaluation and treatment of Internet addiction. In L. VandeCreek & T. Jackson (Eds.). Innovations in Clinical Practice: A Source Book (Vol. 17; pp. 1-13). Sarasota, FL: Professional Resource Press.

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