20 October 2012

The shrink is in...cyberspace

by Elizabeth Zelvin

As regular readers of SleuthSayers know, my blog brother Dixon Hill knows all about explosives. My blog sister Eve Fisher visits prisons. And I too have an alternative identity. Am I Wonder Woman? Nope. Outrageous Older Woman? Well, yes, but that’s not what I’m talking about today. In the world of mental health professionals, I’m known as LZcybershrink.
That’s the monicker by which I do counseling and therapy online with clients all over the world on my eponymous website, LZcybershrink.com. I’ve even got the T-shirt. On the back, it says, “Shrink online…grow online.”

I started doing this work around the year 2000, after fifteen years as a clinical social worker, psychotherapist, and director of alcoholism treatment programs in New York. New York City is a therapy-rich town. Walk out the door and spit, and you’ll hit six therapists. So there’s a lot of competition for clients who sound like Woody Allen.
Since I went online, I’ve treated folks who would never have walked into a therapist’s office in their communities: the stutterer, the 400-pound compulsive overeater, the farmer’s wife whose husband is drinking again, the flasher, the rape survivor, the gay guy or lesbian in the military. I’m the only shrink in Manhattan who’s had a client in crisis because her pregnant horse got cancer. I’ve helped a lot of people by doing exactly what I do as a mystery writer: sit down at the computer and let those fingers fly.

Online therapy is still a new field. It attracts a lot of skepticism. How can you connect with people if you can’t make eye contact and hear their voices? How can clients express themselves and convey authentic emotions through the written word? I hope every writer and avid reader can answer that second question. Did Shakespeare convey authentic emotion in King Lear? I think so. Don’t you? My two professions have a lot in common. Both use the medium of the written word expressively. Both are all about connecting with other human beings on an emotional level. And both are careers about which everyone says, “Don’t quit your day job.” ;)

So what do we substitute for visual and aural cues? For one thing, the smileys, emoticons, and acronyms that already form the common currency of Internet communication. As I explain to clinicians for whom I provide online training in online practice skills, these can be more nuanced than you’d think. As an office-based traditional therapist, I would never have winked at a client.
But I can use a winkie to soften a hard truth when I think a client needs “tough love” or to add affectionate irony to what I say. The client can get mad at me and still feel safe by adding LOL to a critical or even hostile comment. That simple ;) or LOL can mean, “You said it’s okay to get angry, and I’m taking the risk of expressing my anger to you. But that doesn’t mean I’m about to quit therapy.” And see how I used the winkie in the line about “Don’t quit your day job” (above)? In that instance, it means, “Hey, I’m kidding—and not kidding.”

Beyond word choice and Internet shorthand, I’ve found I can connect with clients over time by developing shared vocabulary and an intuitive grasp of how each one uses text and pauses to convey resentment, sadness, humor, sarcasm, and a host of other subtleties. In other words, what mental health professionals call the therapeutic relationship springs to life in a chat room just as it does in a therapist’s office. As for clients who work with me by email, some folks naturally dig deeper in narrative, in reaching within and taking time to tell their story than they do out loud in the moment—as every writer knows.

Personally, I have an additional advantage. As all who’ve met me know, I was born to schmooze. I do it face to face at Malice, the Edgars, MWA and SinC events, and book tours, and online on mystery e-lists such as DorothyL and various social media as well as one to one via email. My, um, intense and lively personality comes through whether I’m there in person or keyboarding my way through cyberspace. And please note that well-placed “um.” What was I telling you about the statement it modified? That’s a pop quiz, not a rhetorical question. You can answer by posting a comment. :) My husband likes to tell people that every time he passes through the room, I’m smiling at the computer. LOL Not really. I’m smiling at you, if you’re on the other end of my fingertips at the time. :)


  1. Very interesting… I had no idea. Do you have an on-line murder worked out that way too?

  2. Are your online clients covered by the same protections a walk-in client would be? I assume so, but wonder.

    This was a fascinating post. And, um, as to your question ... you made the meaning beautifully clear in a way I hadn't considered before. Thanks!

  3. Oh, and by "protections" I meant confidentiality. I didn't think you were trying to run a protection racket. lol

  4. Dix, I'm a licensed clinical social worker and a credentialed alcoholism and substance abuse counselor emerita ("psychotherapist" has no legal meaning), so two codes of ethics insure confidentiality, which I consider a sacred trust no matter how the client and I are communicating. I have two different secured chatrooms on my site. Could I be hacked? Sure, but it's never happened. No one ever barged into my office with a gun when I had a f2f practice either.
    Online murder? I invite you to try to come up with a method. Online conspiracy, on the other hand...and of course online fraud and theft are rife in the 21st century. Have you had good news from any Nigerians lately? (BTW, I recently had to decline to treat a Nigerian potential client who really wanted help because Paypal will not do business with anyone in Nigeria, thanks to the ubiquitous scams.)

  5. "psychotherapist" has no legal meaning

    You know, I've always wondered about that.

    And, I’ve been working on something, over the past several months – on and off – with a protagonist who has PTSD, so I’ve been wondering about this question more and more lately (in order to flesh-out the V.A. shrink the protag’s been seeing).

    My (poor, I’m sure) understanding is that a psychiatrist is an M.D. with some other training tacked onto it. (But, I’ve never been sure exactly what that training is.) A psychologist is (it’s always seemed to me) essentially a guy with the psychiatrist’s “tacked-on training” but no M.D. (which is why s/he can’t dispense meds). I’m sure that’s a grossly pedestrian explanation of two very complex educations, but I’m still left wondering: Then what makes a person a “therapist”?

    I assume there’s some level of education and certification involved, but have no idea what that would entail. I seem to have heard that most psychiatrists and psychologists are required to undergo (or perhaps they only “usually volunteer to undergo”) psychoanalysis prior to hanging out their shingle. Is this required for therapists also? Additionally, there seem to be many more types of therapists than there are psychologists or psychiatrists—sex therapists (what in the world is the curriculum for that course of study!?!), therapists who deal with alcoholism, etc. My kids’ schools even have special therapists in the offices.

    Can you give me an idea of what’s involved, here? I’d really like to know, so I can work some of it into this story I’m working on.


  6. Dix, As I often say to clients, there's no short answer to your question. I'm going to take my run before the sun goes down first. I'll get back to you before the end of the day. :)


  7. Re: Earlier reference to "online" murder. How about online teaching of self-hypnosis? Could the person be subject to post-hypnotic suggestion?

  8. Fran, I do text-based therapy. Can a person under hypnosis read or type? I have no idea.

    Dix, let's start with the South's version of why the Civil War was fought: states' rights. This issue is alive and well today in the helping professions. The licensing of professions, including mental health professions, is determined state by state and discipline by discipline (psychiatry, psychology, etc.). Psychiatrists are indeed MDs. They are trained in diagnosis and treatment via medications, so yes, they're the ones that prescribe drugs, and they are also able to sign a patient into a hospital. Psychologists are trained in the way the brain functions and in assessment, ie testing. In some states, I believe licensed psychologists can prescribe, and I know that in at least one state I'm aware of, master's level nurse practitioners can also prescribe. Social workers, my own discipline, are trained in dealing with the interface between the individual and the community or society at large. None of the above makes any of us a psychotherapist. Today, there are many, many therapies, of which psychoanalysis is not the most important or effective. Psychoanalysts spend years studying at one of a variety of analytic institutes and undergoing their own training therapy. There are institutes that train clinicians in some other psychotherapeutic approaches (some of which are based on, for example, different schools of psychological theory). Many psychotherapists, like me, learned our skills while practicing clinical social work (in my case) under professional supervision and gaining experience before getting licensed to do it alone in my home state (New York). It varies widely from state to state. California licenses what they call marriage and family therapists, and that's what a lot of California psychotherapists are. In many states, the majority of practicing psychotherapists are social workers. New York recently created a license for counselors with its own education and experience requirements. LCSWs like me have to have a master's degree in social work. What's generally called "talk therapy" is not the only kind available. Google "EMDR" if you want to learn about a set of physical techniques that have proved very effective for PTSD along with appropriate talk therapy. EMDR is one kind of therapy that I doubt could be done online, though I know some highly experienced clinicians who work online with abuse survivors and have skills in dealing with moments of abreaction or flashback. I wouldn't try it without long experience and terrific and very specific supervision. The few times I've dealt with someone with dissociative identity disorder (aka multiple personality) another severe post-traumatic condition, I've asked for collegial help to make sure I knew what I was doing.
    On top of this, what a particular therapist brings to the table besides the basic skills and experience depends on his or her experience and interests. If you or someone you love are dealing with alcoholism (or think you are but aren't sure), I'd be as good a therapist as any to consult. I also have a lot of experience with dysfunctional families, people in bad relationships, and survivors of abuse, and after 25 years I feel confident that I can really help that kind of client. Dix, email me if you want more help with your particular character with PTSD.

  9. Oops, one error above: I meant to say "training analysis". In most psychotherapies, having been in therapy yourself is not a formal requirement, but I'd be wary of a therapist who hadn't. Wouldn't you?

  10. I wonder if sex therapists share this sentiment for when they recommend clients to take drastic actions (like buying viagra online or something).


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