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Process and outcome efficacy of Internet counseling

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Process and outcome efficacy of Internet counseling
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Groble, Martha Lana Bogardus
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Academic advising ( jstor )
Alliances ( jstor )
Group facilitation ( jstor )
Internet ( jstor )
Learning styles ( jstor )
Personal computers ( jstor )
Psychological counseling ( jstor )
Psychotherapy ( jstor )
Rehabilitation counseling ( jstor )
World Wide Web ( jstor )
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Thesis (Ph. D.)--University of Florida, 2002.
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Includes bibliographical references.
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Also available online.
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Vita.
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by Martha Lana Bogardus Groble.

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PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING














By

MARTHA LANA BOGARDUS GROBLE













A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2002




















Copyright 2002

By
Martha Lana Bogardus Groble













DEDICATION




This study is dedicated to the memory of


George A. Bogardus 1920-2001

Martha Lucille Clark Bogardus 1920-1975

Potato and beef farmers who recited epic poetry at our dinner table, insisted that we attend school even when the crops needed harvested,
instilled a profound love of learning in their children and
kept the house filled with books.










ACKNOWLEDGMENTS

I wish to express my gratitude to my doctoral committee, James Archer, Jr., Harry Daniels, David Miller and Linda Shaw who permitted me to develop research in a fast-growing and little-researched aspect of counseling. Doug Johnson, the WebCT system administrator was an invaluable resource, problem solver, and unexpected source of encouragement. James Watson and Alan Pappas provided access and administrative support at Santa Fe Community College.

Robert E. Groble M.D. provided the financial backing for this project and granted me leave from office duties to complete it. Kristopher Groble, Loren Groble, and Samuel McFadden interfaced with the facilitators to make their work easier. They ran errands, and provided data entry, proofreading, and other computer, management, and clerical services.

I want to thank the graduate students who facilitated this experiment. Without

them, I could not have completed project of this magnitude. Daniel Pekich, rehabilitation counseling, and Heather McWilliams, mental health counseling each worked with a large number of participants and headed the team of facilitators at the University of Florida and Santa Fe Community College respectively. Lakisha Scott, rehabilitation and mental health counseling; Lamandra Jenkins, school counseling; Anjanette Todd, school counseling; Wendy Marsh, rehabilitation counseling; Angela Falcone, mental health counseling; and Lesley LeBaron, marriage and family counseling were seriously committed to the students they facilitated and were dedicated to working with a protocol and theory that might not have matched their own preference. They brought a broad



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range of counselor training, personal interest, and racial diversity to the performance of this research.

I appreciate the instructors who permitted me to use precious class time to recruit participants and who, in most cases, supported my effort by providing the added incentive of extra credit to their students Laura McCarthy, Dawn Snipes, Michelle Murphy, Kitty Fallon, Natalie Arce, Kim Fugate, David Marshall, Keith Carodine, Alan Pappas, Michael Smith, Joyce Off, and Paul Stem. I would be remiss if I did not acknowledge all of the participants who shared issues that were sincere and intimate to them with their facilitators so that we could learn more about the counseling process and outcome in cyberspace.





























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TABLE OF CONTENTS
Page
DEDICATION ......................................................... ......................................... iii

ACKNOVVLEDGM ENTS .............................................................................................. iv

ABSTRACT ............................................................... .......................................... x

CHAPTER

I INTR ODUCTION ....................................................................................................... I

Scope of the Problem ................................................................................................... 7
Theoretical Framework .............. ................................................................................. 9
Statement of the Problem ........................................................................................... 14
Purpose of the Study .................................................................................................. 15
Need for the Study ..................................................................................................... 15
Rationale for the Study .............................................................................................. 16
Research Questions ................................................................................................... 17
Definition of Term s ................................................................................................... 17
Counseling term s ................................................................................................ 17
Computer Terms ................................................................................................. 18
Organization of the Study .......................................................................................... 20

2 REVIEW OF LITERATURE .................................................................................... 21

Internet Counseling Basic Constructs ........................................................................ 21
Social Presence .............................................. ................................................... 22
M utual trust or trustworthiness ............................................................................ 28
Internet Counseling Issues ......................................................................................... 29
W ebsite Security ................................................................................................. 29
Legal Considerations ........................................................................................... 34
M odalities ........................................................................................................... 35
Telehealth/Telem medicine .............................................................................. 35
E -m a il .......................................................................................................... 3 5
Chat/Conferencing ....................................................................................... 36
M ulti-modal ................................................................................................. 39
Unidirectional Information Only .................................................................. 40
Guidelines for Ethical Practice of Internet Counseling ............................................... 40




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Credential Validating Referral Sites .................................................................... 41
Advantages of Internet Counseling ...................................................................... 45
Disadvantages of Internet Counseling ................................................................. 46
Cognitive Behavioral Counseling M odels .................................................................. 48
Cognitive Behavior Therapy ............................................................................... 49
Brief Cognitive Behavior Therapy ...................................................................... 51
Using Brief Therapy with Undergraduates ............................................. ................... 53
Undergraduate Personal Growth Concerns .......................................................... 55
Individual Information Processing Differences .......................................................... 56
Demographic Factors .......................................................................................... 56
Learning Style Theory ........................................................................................ 56
Academic Learning Styles ............................................................................ 57
Temperament Learning Styles ...................................................................... 59
Learning Style Conceptualization Comparison ............................................. 60
M easuring Information Processing ............................................................... 60
Personality Attitudes ........................................................................................... 62
M easuring personality attitudes .................................................................... 63
Counseling Process and Outcome .............................................................................. 64
W orking Alliance ......................................................................................... 65
M easuring Therapy Outcome ....................................................................... 66
Application in this Study ........................................................................................... 69

3 M ETHODOLOGY .................................................................................................... 71

Statement of Purpose ................................................................................................. 71
Hypotheses ................................................................................................................ 71
Descriptions of Variables ........................................................................................... 73
Dependent Variables ........................................................................................... 74
Independent Variables ......................................................................................... 74
Population ................................................................................................................. 75
Sampling Procedures ................................................................................................. 76
Data Collection Procedures ........................................................................................ 77
Instrumentation ......................................................................................................... 79
W orking Alliance Inventory (Client) ................................................................... 79
W orking Alliance Inventory (Therapist) .............................................................. 80
Outcome Satisfaction Questionnaire ................................................................... 80
M yers Briggs Type Indicator Form M (M BTI) .................................................... 81
Center for Innovating Teaching Experiences Learning Styles Inventory (CITE).. 83 Demographics ..................................................................................................... 84
Data Analyses Procedures ......................................................................................... 84

4 DATA AN ALYSIS ............................................................................................... 85

Descriptive Statistics for Dependent M easures .................................................... 85




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Participant Dependent Variables Analysis ................................................................. 86
Predicted future use (participant) ......................................................................... 88
Level of Computer/Internet Skill ......................................................................... 90
Outcome Satisfaction (Participant) ...................................................................... 91
W orking Alliance Inventory Total (Client) .......................................................... 92
W orking Alliance Inventory Bond (Client) .......................................................... 93
W orking Alliance Inventory Task (Client) .......................................................... 93
W orking Alliance Inventory Goal(Client) ...................... I ................. I .................. 95
Facilitator Dependent Variable Analysis .................................................................... 95
Outcome Satisfaction Questionnaire .................................................................... 96
W orking Alliance Inventory Total (therapist) ...................................................... 97
W orking Alliance Inventory Bond (therapist) ...................................................... 98
W orking Alliance Inventory Task (therapist) ....................................................... 99
W orking Alliance Inventory Goal (therapist) ..................................................... 101
Qualitative Analysis .......................................................................................... 103

5 SUMMARY, CONCLUSIONS, AND IMPLICATIONS ......................................... 106

Summary of the Study ............................................................................................. 106
L im itatio n s ............................................................................................................. 10 8
Implications and Recommendations ......................................................................... 110
R esearch ........................................................................................................... 1 10
C lin ic al ............................................................................................................. I I I

APPENDICES

A FORM S AND INSTRUM ENTS ............................................................................. 114

Participant Contact Sheet ................................................................ 114
Informed Consent ......................................................................... 115
Outcome Satisfaction Questionnaire ................................................... 117

B FACILITATOR TRAINING M ANUAL ................................................................. 120

Table of Contents .................................................................................................... 120
L o g istics .................................................................................................................. 12 1
Session Structure Guidelines ................................................................................... 124
Therapy Plan and Progress Notes ............................................................................. 127
Facilitator Checklist ................................................................................................. 128
Sample of tracking sheet .......................................................................................... 129
W ebCT samples screens .......................................................................................... 130
Required Reading Study Protocol ............................................................................ 132
Required Reading College Student Counseling ........................................................ 133





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C COMPUTER-MEDIATED SESSION TRANSCRIPT ................................ 134

LIST OF REFERENCES .................................................................... 144

BIOGRAPHICAL SKETCH................................................................ 160
















































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Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING By

Martha Lana Bogardus Groble

December 2002


Chair: James Archer Jr.
Department: Counselor Education

This study examined the process and outcome efficacy of Internet counseling by comparing it to traditional face-to-face counseling in an experimental environment. We recruited 123 undergraduates from fourteen classes in two institutions of higher education. Students volunteered to participate in three personal growth sessions and complete five surveys. Ten graduate students were trained to conduct brief cognitive behavior therapy in personal growth sessions within the research protocol. Facilitators were trained to use the chat room and survey functions of the University's secure remote classroom system WebCT.

Participants were randomly assigned to the face-to-face or computer-mediated condition. Facilitators conducted an equal number of sets in each condition but each participant was seen in only one of the two conditions. The demographic survey was conducted in the classroom during recruitment while the other four surveys were completed after the last of the three personal growth sessions in the WebCT survey site, whether the participant had been assigned to the face-to-face or computer-mediated condition. Facilitators completed two surveys after each set of sessions.



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Process efficacy was measured with the Working Alliance Inventory (WAI), forms client and therapist. The WAI provides a score for total alliance, and sub-scores for bond, task, and goal, key factors in the development of a therapeutic milieu. Outcome efficacy was measured with a researcher developed Outcome Satisfaction Questionnaire with three scales, outcome satisfaction, computer skill level, and prediction of likelihood of future use of computer-mediated counseling.

The independent demographic variables, age, ethnicity and gender, were collected from the contact information form completed during recruitment. Learning style preference was determined using the C.I.T.E. Learning Styles Inventory and the Meyers Briggs Type Indicator (MBTI). Personality attitude preference introversion or extraversion was determined using the MBTL

Significant main effects were found for the academic learning style systems and for gender. Significant interactions were found for gender by condition indicating that males reported greater process ability in the face-to-face condition contrary to a study hypothesis. No significant results were found for age, ethnicity, introversion/ extraversion or research condition. Recommendations for further research and clinical applications are discussed.















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CHAPTER I
INTRODUCTION


At the dawn of the 2e century, the fledgling professions of psychiatry,

psychology and counseling were beginning. As the 20 century begins a radically different service delivery method, which may in fact generate a radically new helping profession, is occurring. The current world population of Internet users is estimated to be around 349 million and growing (Stubbs 2000). A segment of these users are accessing mental health services variously known as Telecommunications, Telehealth, and Telemedicine. Telecontact, between a mental health provider and a mental health consumer, may simply be a plain old phone call, to reassure a patient that his or her medication has been called into the pharmacy; a copy of an e-mail of a typical interaction with a troublesome relative, which records the transactions while they are fi7esh, for processing in the next scheduled therapy session; peer moderated bulletin board support groups; video conferencing to train parents how to care for children with seizure disorders; live, interactive Internet dream work with a renowned dream therapist; or a very complex, surrealistic virtual reality counseling world. Computer-mediated counseling is in its infancy. However the generic and programming code necessary to bring it to maturity is already in place for interactive, graphic (sound, visual, and animated) virtual worlds where clients can choose avatars or symbols to represent themselves and to characterize the psychotherapy issues salient to their needs.




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Although the technology and evolution of virtual reality are 30 years old, its

application in counseling has not yet been significantly engaged. The virtual counseling world is the quintessential postmodern constructionist therapy environment. Fink (1999, pp. 28-29) reasoned, "computer-mediated communication (CMC), clearly a postmodern phenomenon, are a form identified by the mediator (the computer) as well as by the communicator (the virtual ego). The machine determines existence.... (u)sing present technology, CMC tends to be fluid, cycling, and devoid of social cues, which constitute modernity. Accordingly, psychotherapy that uses CMC is also amorphous, shifting in response to context, technology and the nature of patient interaction." In essence, the counselor and client co-create the cyber counseling experience in the material processed behavioral issues, distorted thoughts, troubling problems, faulty cognitions, overwhelming emotions and in the very essence each participant chooses to contribute to the structure of the working space. Language, spoken or written, forms the connection between two people. Stanley (2001) argued that "rather than language being a reflection or miffor of social life, language itself constructs social life when it is practiced. Discourses produce different versions of this social life, different realities. The goal of discourse analysis then is not to improve upon people's accounts, but rather to understand how they are practically achieved."

Much of the power differential between client and counselor dissipates when each presents without the hallmarks of embodied age, race, gender, physical attractiveness, size and shape, native language, dialect, speech impediments, or peculiar mannerisms, which color and may distort face-to-face communication with preconceived stereotypes and subtle biases. For example, the researcher had a revealing chat experience with an





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American living in Iceland. This was a personal recreational activity, not a professional relationship. While both were using an AOL Dream chat channel, the person in Iceland "popped-in" to the researcher's screen via the private channel (instant messenger) when the researcher mentioned that she lived in Jacksonville, Florida. The person in Iceland had moved from Jacksonville Naval Air Station to the Iceland Naval Air Station and was lonely. The researcher was familiar with both geographic locations, both Naval Air Stations and with military-family life. The researcher assumed that the person with whom she was chatting was a young wife of an enlisted sailor. The chat contents were volcanoes, glaciers, lava beds, hot water lagoons, things to do in Reykjavik, Icelandic mythology, other exotic locations familiar to both. The researcher terminated the interaction when she learned that her cyber-friend was a 12-year-old girl. Nothing had ever been discussed that was inappropriate when talking with a child. Nothing had ever been discussed that the researcher had not discussed with hundreds of children that age during her career as a natural history museum curator; however, a personal bias of how, or when or for what reasons one related to a child had been violated (a surprising revelation to the researcher). The girl in Iceland had never claimed to be anything other than what she was a situationally lonely and resourceful kid who moved all too frequently to become rooted in any conventional community, a person regardless of age who was interested in relationship, friendship, computer communication and natural history. One would think that age should not matter in this situation but it did. Most saliently, it is precisely for this population (the geographically isolated) that telehealth, telemedicine, and cyber-counseling are most strongly advocated. In the more formal setting of cyber-counseling, intake information would provide basic information if the





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client chose to respond accurately. However, in virtual reality one can role play age, race, gender, physical attributes and try on a vast range of solutions from which to select practical ideas to apply in his or her social-gravity bound life. The counselor in virtual sessions will not only be aware that the client may be role-playing but will need to develop new theory which promotes and capitalizes on a therapeutic world free from factors that often may actually be the source of the clients' distress. This radical new formulation of therapy may be analogous in the physical sciences to work done in space in the absence of gravity. Obviously one does not live long in the absence of gravity without serious physical consequences (e.g., loss of bone mass and tissue density). However, as a special condition to accomplish a specific end (e.g., re-growing tissue more quickly and with less pain) it has therapeutic advantages heretofore unavailable in theory or in practice. The powerful value of such study is clearly demonstrated by a global community's willingness to engaged in the high risk, construction of our third multibillion-dollar facility for such research the International Space Station (preceded by Skylab and Nfir).

Cyber counseling therapy in the absence of the weight and pressure of social

markers allows a healing space, not a long-term residence for the client. Just as NASA researchers and their Russian counterparts must experiment and learn about the weightless environment available in near outer space, mental health researchers must experiment and learn about the social and relational weightlessness of cyberspace. Cyberspace then presents the constructionist need for a completely new theory of counseling, a completely new way of thinking about counseling, not just a new delivery system.





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Entering cyberspace, then, disembodies the counselor and the client. In therapy in cyberspace, the nature of the interaction first deconstructs the everyday givens of the counselor and client, then the two co-construct a new healing reality through the therapeutic dialogue. Is that not the crux of psychotherapy helping, guiding, facilitating, and coaching clients to discover, learn, or experience their story, their inner dialogue in a new, more self sustaining way? The major mental health professional organizations (National Board of Certified Counselors, American Counseling Association, American Psychiatric Association, American Medical Information Association, American Psychological Association, Commission on Rehabilitation Counselor Certification) agree that now, in the infancy of Internet counseling is the time to set the values, ethics and discipline of this new opportunity (NBCC 1997, NBCC 2001, APA 1997, ANHA 1998, ACA 1999, APA 2001, CRCC 2002).

Virtual Psychotherapy will have as little in common with the theory, context, content, and outcome of contemporary psychotherapy as contemporary psychotherapy has with priests and shamans. In the pre-modem or pre-science era, priests and shamans healed physical, emotional, and spiritual distress based on observations and beliefs about the natural and supernatural world, using plant materials, astronomical observations, beliefs about supernatural interventions and such. In the 1990s and 2000s these ceremonies continue but it is unlikely that Blue Cross Blue Shield or any other third party payer would assume financial responsibility for a Sufi whirling dervish, a Greek Orthodox exorcism, a Pentecostal spiritual slaying, an Episcopalian laying on of hands healing service, a Sunni (Lapland) sweat lodge, a Kiowa medicine wheel, a Lakota buffalo hide ceremony, Saginaw Chippewa eagle feature ceremony, yogi fire walking





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treatment, or a Huichol peyote ceremony, even though these practices are far more ancient and continuous than modem psychology and have anecdotal efficacy (which, admittedly, is difficult to quantify). In the modem era of scientific understanding and explanations, physical illness and emotional distress have been dichotomized and spiritual meaning has been severed from the treatment arena. Postmodern disappointment with the limitations of science has revisited issues of holistic medicine, prayer, faith, sympathetic magic (e.g., crystals), imitative magic (e.g., smoke, feathers) and worldview in the relief of distress. The same is projected for the postmodern era and cyber counseling.

Notably, all pre-modem and modem treatments recognize the value of a helping relationship between the helper and the person seeking help, and a satisfactory outcome. The outcome must be satisfactory in many or most cases or the method would have become extinct, or at least superseded by major reformulation (e.g., trepanning to high technology brain surgery, leaches to lancing).

Disembodied, asynchronous, and globally accessible therapeutic models will

expand the limits of thought and theory about the necessary and sufficient conditions of therapy and the nature of therapy. Language and overt self expression have always been the working matter of counseling i.e., Freud's talking cure however, language and imagination will predominate in cyber counseling and will require new conceptualizations of the essence of language in a polyglot world community (Shotter 1993). The language of the Internet is English, American English (Fink 1999). English is the lingua franca of commerce and science. Internet therapy were influenced, limited and contaminated for clients whose native language is not English even though they may





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have learned English in a country or culture that places high value on knowing English and teaches it beginning in first grade.

English as a second language has been identified as a multicultural issue in counseling. How much greater will this issue become, in a global environment? Counseling laws, where they exist, tend to confine counseling to the state of the therapist's licensure; however, there are no International constraints. A potential client can be asked to affirm that she or he lives in the state of the therapist's licensure. However that does not mean that the person does, or if he or she does that he or she lives in an acculturated community. ff a person's English or Spanish appears to be adequate to the counseling demands, can we assume that the person is keying in his or her comments directly through the computer, or is the client talking to a typist who enters the comments, or to a translator who must interpret both sides of the communication inadvertently and subtly changing each side. Web cam technology offers some solutions, or hope for solutions to the disembodied and perhaps linguistic problems posed in Internet counseling. An area of counseling is likely to evolve in the virtual reality model that is independent of physical and verbal cues.

Virtual reality models and virtual reality role playing have 30 years of history and refinement from the worlds of virtual gaming and virtual socializing. Fundamental issues of human presences, viability, efficacy, ethics, limitations, indications, contraindications, national and international licensing and liability and risks to clients must be thoughtfully discussed, debated and researched.

Scope of the Problem

Psychotherapists are using the Internet to provide a full range of mental health services. Powell (1998) surveyed licensed Internet counselors listed on the Metanoia





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website. She learned that the 13 respondents served 445 clients in 1995, 947 clients in 1996, and 1344 clients in 1997. Over 15,000 health care related web sites were reported in 2000 (Dunaway 2000). While many of these are telehealth and referral, if only 5% are counseling and therapy sites, and if 1997 statistics are applied to that 5%, nearly 100,000 clients are presently receiving mental health services via the Internet in the absence of empirical data to support the efficacy of this service. Of Powell's respondents, 85% primarily used email for their Internet service; however 33% of these counselors had chat capability and none were using virtual reality technology. These figures do not include peer-moderated electronic bulletin board, peer-moderated chat rooms and private messages.

Counseling issues included relationship issues, depression, family issues, substance abuse, and anxiety (Powell 1998). in 2001, the organizers of the HealthyPlace.com website both list and recruit mental health professions, creating a network of referrals and some measure of credential verification. Members are encouraged to provide supervised web sites, called communities, in the areas of abuse; ADD/ADHD; addictions; alternative mental health; anxiety and panic disorder; bipolar disorder; chronic pain; depression; dieting; eating disorders; gay, lesbian and transgender issues; obsessive-compulsive disorder; parenting; personality disorders; relationship; self injury; and sex/sexuality. "Partners" are encouraged to manage a complete website, write a topic specific column, be the community's "ask-a-doc7' columnist, maintain a journal/diary, manage an e-zine or write an Internet newsletter. Holmes (2001) whose screening appears to be more selective, has links to over 700 counseling sites- The owners





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of Psychnet.comn sell mental health related domain and the tools to develop them at http://www.psychnetcom.

Concerned professionals began researching the Internet services, even before the Internet became available to the public in 1994 (Colon 1994). Professional organizations have been debating salient issues (Holmes 1997). The federal government has passed a telehealth bill (U.S. Congress 1997, HCFA, 1996, HCFA, 1999). In 1997 the state of California enacted the first state law restricting California therapists to in-state Internet clients (Maheu 2001). The American Counseling Association researched current practice in distance learning related to mental health and cyber counseling. A major recommendation from that study was the need for research in the area of cyber counseling (Brown & Walz 2000). Cyber counseling research must build the theoretical foundation and constructs of Internet communication and of mental health counseling.

Theoretical Framework

The theoretic fr-amework for this study consists of the constructs of social

presence, (Lombard 1997, Reid, 1994), trustworthiness (Edwards 2000) and intimacy (Robson 1998) in cyberspace, counseling in cyberspace, person centered alliance building skills, brief counseling, learning styles, and personality traits. "Psychotherapy is a human relationship that heals" (Suler 1999). For a relationship to develop both participants must be involved in a personal, dynamic manner. Earliest theories of the Internet as simply an impersonal source of information were quickly replaced by the information foraging cognitive model (Priolli 1999), the sociological "gathering and communicating model" (Sproull 1997) and the anthropological expanding human experience: understanding artifacts, and culture model (Mantovani 200 1) to better reflect the evolution of Internet use and the experience of Internet users. The Social Presence Theory is a micro theory





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that identifies six components of social presence, a prerequisite to interpersonal relationship on the Internet and, therefore, a prerequisite to Internet counseling -- social warmness, realism, transportation "you are there," "we are there," perceptual and psychological immersion, social actor within the medium, and medium as social actor (Lombard 1997). Almost all counseling theories emphasize the importance of the interpersonal relationship between the counselor and the clients, although they may vary in the manner in which they deal with the helping relationship, transference, counter transference, or working alliance. It is reasonable then to infer that social presence is a key concept for the development and evaluation of Internet counseling. It should be noted that several projects have attempted to create computer-as-counselor (Wizenbaum 1966, Maes, 1995, Ookita, 2001). However, this study examines the human counselor client interaction with computer as communication mediator. Computer-mediated communications is not, in and of itself, psychotherapy, no matter how personal, rewarding, helpful and satisfying it may be. Hampton and Houser emphasized that "the Internet is a tool and it has no more inherent ability to cause harm than a telephone. Like other tools, if we use it properly, it will be helpful and beneficial. However, if we misuse it, the consequences will be detrimental (Hampton 2000)." A century of research and application have demonstrated that psychotherapy is a particular form of communication supported by heuristic theory, discrete techniques, and demonstrable outcome results. Now research must do the same for computer-mediated communication so that Internet counseling will be helpful and beneficial rather than detrimental.

This study was designed to contribute to that needed body of research. To do so, the study compared brief cognitive behavioral theory applied in personal growth





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session's used in two conditions, face-to-face or computer-mediated sessions. Cognitive behavioral theory defines and describes salient constructs as cognitive events, cognitive processes, and cognitive structures (Meichenbaum 1988, Meichenbaum 2000). Cognitive events are conscious, identifiable or readily retrieved thoughts, images, and accompanying feelings. These events include internal dialogue, expectations, espoused beliefs, and appraisals. Cognitive events occur when the person's automatic behavior is interrupted, when one is uncertain about making a choice or judgment, when one is troubleshooting, and when one is exercising recall or reconstruction of an event or idea.

Cognitive processes are defined as the way a person processes information.

These processes include information storage, search, retrieval and application. Cognitive theory suggests that information is received, encoded, stored, retrieved and applied to a given situation based on the beliefs and values of the individual. That is, not all possible information, which one encounters, is stored or retrieved. There is a selection process based on salient beliefs and values. An artist, for example, may store shape, form, color, light, and texture information extant in the everyday world, which others would miss entirely. The artist can retrieve that information in another setting because it is relevant to his or her worldview. At least three of these cognitive processes, confirmatory bias, mental heuristics, and meta-cognition, are important in psychotherapy. Confirmatory bias is a process by which the person stores and retrieves information that confirms a belief or value without questioning the underlying belief Using this process, the individual filters out any contrary information or ambiguous information, denying that individual necessary information in the current situation. Mental heuristics are processes or templates for making decisions in ambiguous situations. Stereotyping is a common





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mental heuristic. Meta-cognitions are ways of thinking about and controlling cognitive processes. Scarlett O'Hara's "tomorrow is another day" or little orphan Annie's "the sun will come out tomorrome' are meta-cognitions, cognitive processes or templates that automatically inform that believer to ignore today's disappointments, fears, worries, and concerns because they were gone tomorrow. Cognitive structures or schemes are templates that are pervasive, readily accessible, and reflect personal themes.

Each theory of psychotherapy has generated techniques or procedures, that use,

operationalize, and/or apply the theory in concrete situations with particular clients. Beck and his colleagues (Beck 1979) emphasized that cognitive behavioral therapy is collaborative work, which begins with rapport. To develop this working relationship, they recommend that a good base for building of rapport is simple courtesy not keeping the patient waiting, remembering important facts about him, and giving a sincerely warm (but not effusive) greeting. Maintaining eye contact, following the content of the patient's talk, trying to infer and reflect the patient's feelings, and phrasing questions and comments diplomatically help to build rapport. The choice of words and labels is important (p. 53). For example, "non-productive ideas" is preferable to "neurotic," "sick," or "irrational" thinking. The working relationship in cognitive behavior therapy, however, is more than rapport building, which can be accomplished in a hierarchical relationship as well as in a collaborative relationship. In a cognitive behavior therapeutic relationship, the therapist and patient work together to determine how and what the patient thinks, the basis for such thinking, and the practical benefits and losses that result from such thinking. The patient's unique contribution to this collaborative effort is to provide the raw data for this inquiry, that is, to report his





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thoughts, feelings, hopes, dreams and wishes. The therapist's special contribution is to guide the patient about what data to collect and how to utilize these data therapeutically (p. 54). Other collaborative techniques include "authenticating introspective data7, investigating underlying assumptions," "setting up experiments7, and "homework assignments" all of which are conceptualized as making the client his or her own 'folk' scientist whose research is focused on his or her own best interest, personal problem solving and successful living.

The process of therapy and the outcome satisfaction as reported by both the participant and the facilitator were evaluated to determine the efficacy of computermediated counseling. A therapy outcome is related to both what happens during the therapeutic process and what the participants bring to the process. This study examined cultural factors and personality traits that the client brings to the therapeutic process, gender, ethnicity, learning style, and personality traits.

Learning style theory, an operational application of information processing

research, is an important construct that identifies inherent learning strength and examines differential sensory and social ways in that people prefer to learn and learn most successfully (Babich 1976). Personality traits or the hard wiring of individual differences in attitude, response to the stimuli, collection of information from the world and source of energy and authority were simultaneously suggested by Jung and by the mother daughter team, Myers and Briggs. Myers and Briggs (Myers 1962) operationalized Jung's theory in the Myers Briggs Type Indicator (MBTI). Of particular interest in this study is the introversion/extroversion scale, because Reid (1994) and Fink (1999) each suggested that computer-mediated communication favors those with an introverted attitude. Jungians





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have researched temperaments and their contribution to the manner in which people prefer to learn either in a formal educational setting or in life in general. This more pervasive learning style was examined as well as the academic specific learning style developed by the Wichita Public School System. Computer-mediated communication, computer-mediated social presence, cognitive events, cognitive processes, cognitive schemes, learning style, personality type, and working alliance are the major constructs that form the theoretical foundation of this study.

Statement of the Problem

It has long been the sin qua non of the helping professions to "Do No Harm". Clients seek counseling because they perceive it offers hope, help, assistance, and guidance in a time of confusion, pain, loneliness, or danger. Professional and governmental agents exist to assure clients that the professional from whom they seek help is trained, qualified and practicing in a safe and proven manner. Insurance companies and other third party payers often refuse to reimburse any treatment that is considered unproven or experimental. When new methods are developed, they must be reproducible and scrutinized by the professional community to insure that they are safe and effective. It cannot be assumed that when there is major change in the manner in a service is provided, the therapy is identical to previously validated methods. Internet counseling must meet the same standard of applicability and efficacy that is required of all other modes and forms of counseling. Research must inform clinicians regarding appropriate selection of clients who are likely to benefit from Internet counseling and must demonstrate useful theory and techniques in the cyberspace-counseling environment. One size does not fit all, and one technology certainly does not fit all.





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Purpse of the Stud

The purpose of this study was to compare and contrast the development of

working alliance (Horvath 1993, Horvath & Greenberg 1986, Horvath & Mars 1991, Horvath & Symond 199 1), and outcome satisfaction with traditional face-to-face brief group counseling and with computer-mediated brief group counseling. The effects of learning style (Babich 1976) and personality traits were analyzed to determine if potential differential efficacy of face-to-face or computer-mediated counseling could be predicted. The study will examine which, if any, specific learning style and personality traits are predictive of success in one modality or the other.

Need for the Stud

Few studies exist to guide psychotherapists who decide to move all or part of their practice to the Internet. Most of these studies are surveys and other qualitative studies as is appropriate for developing heuristic for a new area of inquiry (Barak 1999, Colon 1994, Dunaway 2000, Fink 1999, Harris-Bowsbey 2000, Stubbs 2000). Virtual Reality

(VR), the high end of Internet technology is being studied with statistical rigor in the treatment of phobias (North 1994, Rothbaum, 1997), cardiac illness in children (Bers, 1997), and chronic pain at a burn clinic (Patterson & Hoffman 2000). Ethics working papers and guidelines exists to structure Internet psychotherapy (NBCC 1997, ACA 1999, AMIA 1998, APA 1997, Brown & Walz 2000, Holmes 1997, NBCC 2000, CRCC 2001) and there is no dearth of technology and technical assistance to develop and market Internet therapy. There is however, a critical need for empirical research to analyze typical Internet therapy after almost a decade of development.

The primary therapeutic use of the Internet appears to be Internet support groups (King 1998). Because of this widespread use, the American Psychological Association





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conducted an Internet support group symposium at their annual convention. Barak and Wander-Schwartz (1999) report one of the only studies of Internet therapy. They describe their study as preliminary, warned that its findings should be interpreted with caution and called for intensive research. Several professional and scientific questions of relevance include: Is Internet therapy useful, beneficial, satisfactory, and efficacious? Is Internet therapy harmful? Does Internet therapy immunize potential clients to effective face-to-face treatment? Is Internet therapy a technology placebo? Is Internet therapy "snake oil"? Do the personality traits of the client influence the effectiveness of Internet counseling? Is the Internet, as one author suggests, "revenge of the introvert?" Is a visual learning style more conducive to effective Internet results than a verbal learning style? Does the physical isolation of computer-mediated psychotherapy hamper the success for clients with social group learning style preference? These are but a few of the questions that need to be considered, especially if the cyber client is to be provided with appropriate services, the psychotherapist is to remain in compliance with his or her professional ethics and credentials, and if the insurance industry is to recognize and reimburse Internet therapy.

Rationale for the Study

This work contributes to the foundation for the lower end technology interface. It will benefit counselors who wish to work well and ethically Internet. With this and similar research, counselors will have tools to determine which clients are best served by Internet counseling, and which clients need to be seen face-to-face. It will benefit clients who are geographically or situationally isolated from counseling services to be able to make an informed decision about Internet counseling. Since the federal government health benefit program has long supported some forms of telehealth and telemedicine as a





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cost- containment means, a strong research effort is needed to support the claims of counselors and clients for third-party payment.

Research Ouestions


The following six research questions were examined in this study:

1. Is brief, Internet counseling as effective as brief face-to-face counseling?

2. Does working alliance develop equally well in brief, Internet counseling and in
face-to-face counseling?

3. Does the information processing style (visualizing/verbalizing) of a
participant influence the effectiveness of Internet brief cognitive counseling?

4. Do personality attitudes (introversion/extroversion) of client affect the
efficacy of Internet brief cognitive counseling?

5. Does the ethnicity of the client affect the efficacy of Internet brief
counseling?

6. Does the gender of the client affect the efficacy of brief cognitive Internet
counseling
Definition of Terms

Counseling tem

Learning style the sensory and social process by which an individual acquires, encodes, stores, and retrieves information, including visual, verbal, kinesthetic, tactile, social-individual, social-group, expressive-oral and expressive-written (Babich 1976). Personality Traits as defined by Jung (1923) these are psychological flijctions of thinking, feeling, sensing, and intuiting, which interact with attitudes of introversion and extroversion. Myers (1962) added the constructs of judging or perceiving (cf. MBTI). Each individual has preferred functions and attitudes that he or she generally prefers to use to collect information about, and interacts with his or her intrapersonal and interpersonal environment.





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Working Alliance the therapeutic relationship that develops in the counseling environment to facilitate success. Three components of the working alliance are the bond between client and counselor, mutual agreement on the goal of therapy, and mutual agreement on the tasks of therapy that will accomplish the goal (Bordin 1976). Computer Terms

Synchronous (antonym asynchronous) means happening at the same time or moving at the same rate of speed or having the same rate and phase as vibrations (Gurainik 1979). These are key concepts in Internet communication and refer to the ability of people to communicate at the same time (synchronous) from any computer in the world or near outer space or to communicate at different times (asynchronous). Examples of synchronous interactions are text chat and media chat. Email and bulletin board discussions are asynchronous. (Suler 1999). Chat real time, live, or synchronous text conversation between two or more people located at a computer keyboard anywhere on the planet or in near outer space. (Young, 1998)

Cyberpc a term coined by science fiction writer William Gibson (1984) to describe

the space that exists between people, computers, satellites and phone lines E-mail generally one to one written "letters" but courtesy copies, blind courtesy copies, and group mailing are also common (Young 1998). Encrytion applying mathematical algorithm to plain text to produce apparently unintelligible text for security purposes during transmission (Smith 1997). Telehealth/telemedicine developed originally by NASA (2001) in the early 1960's to provide health care and monitoring for astronauts, beginning with Project Mercury. It





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provides assistance in disaster stricken areas throughout the world and applies spacebased technology to terrestrial medical care. URL the address or location of information on the Internet. The acronym stands for Universal Resource Locator (Young 1998), although Berner-Lee (2000), a particle physicist who created the World Wide Web, originally used URI for Uniform Resource Identification and the terms are often confused because the URI is still used for addresses on the Internet outside the worldwide web. The URL of a popular search engine for example is http://www.gxoogle.com. While most clients will see the URL, the direct form is htp :1216.199.19.139/ the URI of a small business in Jacksonville. An email address is not a URL or a URI but rather a hyperlink to a section (bin) within the service provider's website.

Virtual Reality (V)-immersion technology currently being used at MIT and elsewhere to treat pain and phobias. VR is a graphic and animation rich computer environments, which simulates visual, auditory and tactile sensations. For microcomputers, (PCs and Macs) yR uses MOO (MUD Object Orientation) virtual reality programming code that allows the creation, use, and manipulation of items on the screen. MUD is Multi-User Dungeons, (now also Multi-User Domains, Multi-User Dimensions) a virtual world originally developed in the 1970s and 1980s for playing adventure role-playing games. MUSH is Multi-User Shell, a programming system that allows users to develop and manage either an adventure or a social MUD (Bruckman 1995). This technology can potentially be used to develop VR counseling from any computer given adequate bandwidth and baud rate to both the counselor and client computers.





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Organization of the Study

This study consists of five chapters, an abstract, three appendices, and a list of

references. The abstract and introduction present the Internet and counseling context for the study describing research issues of the growth and professional concerns about Internet counseling. The second chapter reviews relevant scholarly literature on social presence, Internet counseling, face-to-face brief counseling, working alliance measures, outcome efficacy measures, learning styles and personality traits. The third chapter describes the structure of the study, characteristics of the participants, dependent and independent variables observed, measures used, and statistical procedures applied to analyzing the results of the experiment. Chapter four presents the statistical results and chapter five discusses the significant results, potential impact to Internet counseling, limitations of the study, and recommendations for Internet counseling and further research. The appendices contain forms and measures created for this project, protocol for facilitator training and sessions, and a sample computer-mediated session transcript.














REVIEW OF LITERATURE

The relevant scholarly literature is reviewed in this chapter. Topics to be reviewed are research; Internet computer counseling concepts; Cognitive counseling theories; personality traits; temperament learning style; academic learning style, and counseling outcome and process theory. The exiting Internet research, which is primarily qualitative and heuristic, addressed the social and cultural dimension of Internet transaction and the construct of social presence on the Internet a prerequisite to counseling. The advantages and concerns about Internet counseling as discussed by the mental health professional organizations and activists, and current applications of counseling on the Internet. While outcome efficacy of Internet counseling is a concern in all theoretical approaches, for the purposes of this study, the theory used is brief cognitive behavior therapy. Research regarding basic precepts of cognitive behavioral therapy, basic precepts of brief therapy and the construct of working alliance are reviewed. Relevant research about personality traits, theory and application of learning styles are discussed as related to independent variables in this study. The theory and instrumentation for evaluating the independent (personality type and information processing style) and dependent (working alliance and outcome) variables are presented. This chapter concludes with a discussion of the contribution of the existing research to the formulation of the present study.

Internet Counseling Basic Constructs

To counsel in cyberspace, one must first assess the constructs and theories

defining human relations in cyberspace. Counseling is a human interaction, which is a 21





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good deal more complex than ordering a book from Amazon.com. or a rose bush from JacksonandPerkins.com. Is there a subjective component to human interaction in cyberspace? Is there a "person" or "psyche" to counsel? Three major concepts have been discussed at length social presence, trustworthiness and intimacy. These factors create an environment in which a therapeutic alliance can be developed. One of the three essential components of a therapeutic alliance is the development of a personal bond. Social presence, trust, and intimacy or self-disclosure, create the milieu in which a personal bond can develop between the therapist and client. The client and the counselor need to experience a sense of bond, connection, or rapport. The bond can be based on the sense of mutual trust, liking, understanding and care (Bordin 1976, Horvath & Greenberg 1986).

Social Presence.

Is there social presence in cyberspace, and if so, how does it manifest? In

response to the gamut of pressures emanating from the war in Viet Nam and the Cold War, government, military and related universities developed the technology to deliver information around the world and into near outer space almost instantly. At the same time, social, political, humanitarian and radical thinkers were developing experiments in human living that were just as dramatic. The social geniuses of the era readily adapted and defined the ultimate use of the Internet. Rheingold (1994) was perhaps the first social thinker to systematically describe the social and cultural communities that developed on the Internet. The WELL, a San Francisco founded, Internet community dating from the early 1980s, grew out of the social activism, communal living experiments, and democratic philosophies of the 1960s. The personal involvement and





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real life connection among members is illustrated in the following two incidents. The

WELL community organized a massive medical resource location, medicine delivery,

and member return transportation from India to San Francisco when a former member

who had become a Tibetan nun developed a rare liver condition and was destined to die

in India without this heroic, real time, real cash, real resource, unbidden, but greatly

appreciated massive intervention (28-32).

In another case, a prolific member of the WELL committed Internet suicide, the

act of removing all of his years of comments and conversations written into the fabric of

the community. Alert members of the community called him, assured that he sought and

received professional help, and notified his family and other friends. In the end, the

effort was insufficient and the member committed real world suicide. Rheingold mused

"Suicide brings up unusual feelings in any family or
social group. Fortunately, there were one or two
among us who knew exactly how to understand what was happening to us: a fellow who had struggled with years of feelings over his brother's suicide was able to offer wise and caring and credible counsel to many of
us.
There was a real-life funeral, where we brought our
physical bodies and embraced each other and Blair's
family. We were learning how fond we had grown of Blair, and how his death put a milestone in cyberspace.
Marriages had happened and others had unraveled.
Businesses had started and failed. We had parties and picnics. But death seems somehow more real, even if your only participation is in the virtual funeral. How could any of us who looked each other in the eye that
afternoon in the funeral home deny that the bonds
between us were growing into something real? The feelings ran just as high during the virtual part of the
grieving rituals as they did during the face-to-face part indeed, with many of the social constraints of proper funeral behavior removed, the Internet version was the
occasion for venting of anger that would have been
inappropriate in the face-to-face gathering. There





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were those who passionately and persistently accused
the eulogizers of exhibiting a hypocrisy that stank unto
the heavens, because of our not altogether charitable
treatment of Blair Internet when he was alive.
Those of us who had made the calls to Blair and his
shrinks, who went out and met his brother and his
mother and tried to provide them some comfort, had a
different attitude toward those who couldn't bring
themselves to attend the painful event in person but
didn't hesitate to heckle others Internet. People who
had to live with each other, because they were all
veteran addicts of the same social space, found
themselves disliking one another (p. 37)." And ...
There has always been a lot of conflict in the
WELL, breaking out into regular flarnefest of
interpersonal attacks from time to time. Factionalism, Gossip, Envy. Jealousy. Feuds. Brawls. Hard feelings that carry over from one discussion to another (p. 53)."

Thought, feelings, and behaviors are the raw materials of counseling.

Rheingold's experiences provide poignant insights into the thoughts, feelings and

behaviors Internet and in the real life of a multinational, Internet, social community.

From social psychology, the construct of disembodied engagement and personal

interaction over the Imernet has been named "presence'. Lombard and Ditton (1997)

identify presence as the sense that mediated experience (computer, simulation rides,

home theater, video conferencing) is natural, immediate, direct, real and unmediated.

This qualitative factor of mediated communication is crucial to community building and

counseling. "An enhanced sense of presence is central to the use, and therefore the

usefulness and profitability, of the new technologies... These technologies either are now

changing or are expected soon to change many of the ways we work, play and five (p.

2)." Social presence theory was studied early in the advent of mass, affordable access to

electronic media and continue to be important in social psychology and mass

communication research.





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Cyber feminist Plant (1996) warned that the Internet disembodies, degenderizes and promotes yet another form of oppression. Stanley (2001) and others (McLuhan & Friore 1967, Billig 1996, Shotter, 1993, Turkle, 1995) countered that language embodies the authentic self and depoliticalizes the communication. Stanley disputed the concept of virtual space saying, "a social space (is) constructed through which embodiment could be revealed. This reality is "real space," the space that is on the other side of the screen... real space constitutes the embodied practice of social talk (p. 77)." He suggested interpersonal life is a dynamic performance of language constructed in speaking and writing, not in thinking or holding unexpressed opinions and attitudes. "Rather than language being a reflection or mirror of social life, language itself constructs social life when it is practiced. Discourses produce different versions of this social life, different realities (p. 79)." Stanley works with international students for whom life with family and friends of necessity is text based. He analyzed the text-based interviews with distant students/participants and identified recurring themes. Quotation marks are used to signal 'stake' and 'accountability. Subjectivity and reality, marked by the use of"humm" and "erm", Stanley noted is "an archetype of phonetic space (that) has been appropriated for use in cyberspace (p. 86)." He found that the bodily presence of the person using the Internet is present in the use of emoticons (emotion icons) and by typing speed, pauses, and deletions. Language itself embodies in metaphorical phrases. Boechler (2001) makes much the same argument from a cognitive process and concept point of view.

Much of the debate over presence and embodiment (Harris-Bowlsbey 2000, King & Moreggi 1998, Laszlo, Esterman, & Zabko 1999, Miller 1995, Plant 1996, Powell 1998, Reid 1994, Suler 1999, Walther 1996) has or needs to examine how presence,





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emotion and embodiment are incorporated in text-based communications. Letters, missives and discourses were the major form of communication from the invention of writing at least as early as 5,000 B.C.E. until the invention of the telephone, telegraph, and radio in the last I19P century (Bell 1867, Bell 1895, and Marconi 1900). The most common and wide spread convention for expressing emotion on the Internet is the smiley or alternately the emoticon. Early on, the need to encode and covey feelings was recognized in the computer chat space. Carnegie Mellon Principal Research Scientist, Scott Fahlman, (1995) admits


"Yes, I am the one who first suggested the use of the:and :-( glyphs in E-mail and bboard posts sometime around
198 1. People were making sarcastic comments in posts,
others were taking them more seriously than they were
intended (no body language on the net), and silly arguments
were breaking out. So I suggested on one of the CMU
bboards that people explicitly label comments not meant to
be serious with a :-) glyph. Very quickly, this idea spread
all around the world and others started creating clever
variations on the theme. The awful term "emoticons" is
much more recent."

These glyphs (see Z'Boray 1997) are an important part of routine Internet

socializing but are inadequate for expressing the range of non-verbal cues necessary in counseling. Other rules of appropriate behavior (netiquette) on the Internet also evolved to smooth social interactions (Rinadli 1998) and should be observed by the cyber counselor but like glyphs, netiquette is not sufficient for the needs of the counseling relationship. The introduction and development of glyphs and netiquette demonstrate that the need and convention was recognized early in the development of text-based communications.





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Cyber counseling specific conventions have been developed and need to be

researched, developed, enhanced and expanded. Murphy and Mitchell (1998) developed a three-component convention to provide a text-based alternative to the non-verbal cues in traditional counseling. Technique I is called "emotional bracketing. In the text of an email or other text-based communication, the writer puts the emotional tone of his or her thought in parentheses (p. 24). For example, a therapist may be concerned because the client mentioned his car was stolen then skipped without elaboration to another topic. The therapist might write. Let me interrupt here and return to your mention of your car being stolen (concern, puzzled). What have you had to do as a result ... police, public transportation, .? I know you frequently have to take your aunt to doctors' appointment (proud of your commitment)? How are you coping (knowing you have)?

The second tool or technique Mitchell and Murphy developed is called

alternatively "textual visualization" or "descriptive immediacy". They provided the following example:

"If you were standing beside me as I write this, Tanya,
you would notice me stopping often, falling back against the back of my chair saying "that's incredible" to myself.
Your recent successes against guilt are so wonderful that
even now I find myself (right now!) Stopping in the
middle of the sentence, my hands towards the computer
screen, my mouth wide open as if to say "this is amazing.
How did she defeat guilt?" (p .24)."


Third, Mitchell and Murphy encouraged the conscious, deliberate use of literary tools simile, allegory, metaphor, poetry, story telling, and mythology commonly used in face-to-face therapy. These techniques have expanded the repertoire available to therapists well beyond the effective but static emotion or smiley, for expressing





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emotional context, for making content explicit and for making the here-and-now process comments so vital to counseling, in text talk.

Another equally interesting concept is "hyper-personalization7'. Walther (1996) introduced the concept of a reinforcing feedback loop, which he called an intensification loop. He suggested that a person can project his or her idealized self into the communication and be reinforced for that idealized self, increasing the realization of that ideal in their daily off computer life via ego strengthening. He also suggests that when communicators do not have to pay attention to social cues they pay more attention to the text and its meaning. He did not, however, discuss whether this enhances or distracts from therapy.

Patterson (2000) and Riemer-Reiss (2000) each reviewed Internet rehabilitation service delivery and concluded that the Internet offers accessibility, immediacy, advocacy, and competency for rehabilitation counselors and their consumers and also challenges and ethical considerations. Patterson mentioned the availability of vocational information, Department of Labor Statistics, job banks, placement resources, medical information, free or inexpensive assessment tool (e.g., Keirsey Type Indicator, Career Interest Game, Career Key, Birkman Method Career Style Summary and the Self Directed Search), support groups and continuing education. Patterson advised "judicious" use to complement the work of human interaction. Mutual trust or trustworthiness

Trustworthiness, consisting of dependability, reliability and honesty, is essential to a good counseling relationship (Ainesworth 1995). These mirror the qualities Roger's (1957) included in what he considered necessary and sufficient conditions for person centered therapy to be effective. Trustworthiness, on the Internet has been researched by





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Cheskin Research and Studio Archetype/Sapient (1999 because of it is vital component in ecomnmerce. Web site and email security were discussed in length below because cyberspace is mysterious to many users and because privacy, confidentiality and credibility are essential factors for instilling a sense of trust. Intimacy

Intimacy, in a clinical sense, has to do with the amount of self-disclosure exists in a relationship (Robson & Robson 1998). As a relationship develops and matures, the amount of self-disclosure increases and expands. For counseling, self-disclosure is essential. Self-disclosure must be monitored. Too much self disclosure, prior to sufficient development of presence and trust, can rupture a budding relationship just as too little disclosure later in a relationship can regulate it to distant, formal, casual and atrophying because it lacks depth and richness.

Social presence, mutual trust and adequate and appropriate intimacy or self

disclosure exist on the Internet and are richly communicated through email, chat rooms, bulletin boards, and multi- user domains. This research (Sproull 1997, Robson & Robson 1998, Barak 1999, Suler 1999, Mantovani 200 1, Stanley 200 1) is fundamental because without these factors, counseling could not realistically expect to develop a human relationship and personal bond needed for a therapeutic alliance to move the therapy to a satisfactory outcome.

Interne Counseling Isse

Website Securit

Counseling room security is a significant concern especially in university teaching labs and public clinics where sound readily passes through the walls. The problem of "eavesdropping"' escalates on the Internet. Electronic transmissions are most vulnerable





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to security breaches at their origin and at their destination. In transit, the message consists of binary code that has been broken into several "packets" each of which travels the Internet independent of the other. At the destination, they are reassembled and checked for completeness.

Security should be applied at each end point where the message is complete and readable but the counselor can only control his or her end of the communication. It seems obvious that therapy should not be conducted from the client's employer's computer or from a public computer (library, computer caf6, etc.). Ironically, these sites may be the client's only Internet access. Law and legal intervention cannot secure wireless connections to the Internet. Hardwired cable modems or DSL cables are also at risk because they establish a permanent address for the computer access rather than a new one with each dial up making the connect susceptible to deliberate attack. Dial up connections are vulnerable to disruption of service. The client and therapist each have to be responsible for common sense and security on their respected ends of the transmission.

Grohol (2001), who credits himself with creating the term "e-therapy", claims that e-therapy is more confidential and secure than traditional psychotherapy citing thin walled clinics, and patient charts available to clerical personnel as evidence of lack of security in a traditional office or clinic. Grohol does have a point to the extent that unless a therapist sound proofs his or her therapy room, encrypts all telephone calls to patients/clients, and checks the office regularly for surveillance devices, does his or her own transcription, copying and filing, and so forth, most Internet psychotherapy is as secure as its face-to-face counterpart. Workers Compensation required that all case notes relevant to the injury be copied and submitted with the request for payment. How secure





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is that? Physical security is the most crucial place to insure office or Internet privacy and confidentiality. (Smith 1997) In recent spy scandals, the main issues involved missing disks, missing laptop computers, and missing hard drives, not Internet or Intranet security.

Encryption (Smith, 1997) offers the second mode of protecting Internet privacy

but has no application if one uses a cell phone or wireless Internet connection (encryption is legally defined as a munitions in the USA and 40 other countries). Ironically, it is the geographically remote who rely on wireless communication. The average user can connect to the Internet in one of three ways. Dial-up connections use regular telephone lines. In remote areas, some telephone lines still use analog (rotary, pulse) system and cannot dial up an Internet Service Provider (ISP). Television cables offer another way to connect to the Internet, but cable television is likewise not economically feasible for the companies in remote areas and therefore not available to one of the most under served populations. Dish satellite is available in remote areas but because it is wireless, it cannot be legally encrypted. Most high-speed Internet connections rely on microwave towers and as a result are wireless even when offered by the local telephone carriers. Cable high-speed Internet connections are probably the only DSL connections that use physical wire. Internet security is a matter of therapist knowledge and proper application of both hard ware and software solutions (Smith, 1997). T-4 lines are the most secure, most expensive, and least available to the average therapist. Furthermore, even if the therapist has a secure high-speed connection, the actual communication between a therapist and client can only proceed at the rate of the slower system.





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The issues for email, chat, and bulletin board security include authentication, nonrepudiation, public key distribution, and mailing list handling (Smith 1997, p. 287-296). Authentication asks "who wrote the message" did the therapist write the message the client receives, did the client write the message the therapist received. Non-repudiation is important in legal matters, commonly business contracts but, for the therapist and client in potential lawsuits -- divorce, custody, criminal, and malpractice. Public keys are passwords and other encryption devices use to allow discretionary access to information. Mailing list, (e.g., listserv, USELIST) are difficult to encrypt because the decryption must be specific for each receiver.

Cryptography and secret codes has a long history in government, intelligence and military use but equally if not more importantly in business and commerce. Modem cryptography has been spurred by the business and commercial needs of the Internet and by major advances in modem mathematics that provides the means to develop nearly indecipherable code algorithms. The therapeutic community is rightly concerned about privacy and confidentiality. However, "hacking" or breaking into a properly secured computer system, is actually very difficult, rare and targets valuable and marketable sites. With this caveat, the therapist is wise to encrypt his or her site for the protection of the therapist/client communication and use a third party secure payment company, which specializes in the coding/decoding in monetary transactions. This protects both the therapist and the client from external credit card fraud, exploitation, and subterfuge. It is the most complex, expensive and restrictive form of encoding. Companies exist to handle financial transactions because the ordinary transactions of many businesses are not worth the time and trouble required to intercept or forge them. It is a much better





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business strategy to hire out secure credit card processing than incurring the expense and risk of doing it in-house.

Mitchell and Murphy (1998) recommend that all e-mail be encrypted but agree

that it may be too anxiety producing to ask of a client seeking professional help to acquire and learn to use an encryption program (p. 52). E-mail can be encrypted with free or inexpensive software but it only works if it is installed and used properly. PGP (Pretty Good Privacy) encrypts both e-mail and files for a one-time cost. The software "plugs in" to common email programs such as Endora or MS Outlook, to encrypt files, disks and existing email on a hard disk. ZixMail is a secure email application, which downloads free but requires $1 per month payment. Zip-Lip and HushMail are both free secure web messaging services. Messages remain on the server so they cannot be intercepted. Nothing is stored on the clients' computer or the therapists' computer (HON, 1995). The major concern about the use of encryption software is not the quality and usefulness of the software, but the misuse or inappropriate use of the software (Smith, 1997).

The electronic security issues, technological failures and access have as long a

history of research and development as do research on therapy relationships and outcome efficacy (Wright & Greengrass 1987). Electronic security is directly related to ethical issues of privacy and confidentiality. While news media seem to frequently report breaches of electronic security, a close examination of recent espionage incidences reveal that most involve an insider (Lee, Ames, Hansen) who has direct, physical access to the hard drive, server, stolen laptop, software, encryption/decryption devices or paper files. Virtual Private Network (VPN) is the concept of using private computers (desktop,





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laptop, mainframe or server), firewalls, public servers, the Internet and the client's personal computer (Barlow 200 1, Fratto 2000).

Certification authority issue digital signatures after performing background

checks to assure that the company certified is what it claims to be. The personal digital signature certificate verifies that the user is who he or she claims to be. Loss or misuse of a digital signature certificate has serious consequences, comparable to loss or m-isuse of a passport. A digital signature is also analogous to a business or occupational license and bonding.

Legal Considerations

State licensure and states rights are the key legal issues in Internet psychotherapy. Federal and state laws regulate Telemedicine (Congress 1997, HCFA 1996, HCFA 1999). Interestingly, both California and Minnesota have passed laws allowing reimbursement for telehealth services (Jones 1996a, Jones 1996b). California (Maheu 2001) has also passed an Internet psychotherapy law restricting practice to in-state clients. Case Managers, rehabilitation counselors, and nationally certified counselors in states without licensure may be relatively safe practicing under their national certification. There is ultimately no way to know if the person with whom the therapist is communicating is physically located in a state or nation where the therapist has a license or certification. As a result, much of the experimental research on Internet psychotherapy is being conducted in Israel (Barak 1999, Barak & Wander-Schwartz 1999), Australia (Reid 1994, Smith 1997), and Canada (Murphy & Mitchell 1998, Mitchell & Murphy 1998).

Dunaway (2000) discusses both jurisdiction and malpractice insurance issues

"The potential for out-jurisdiction counseling is another hurdle faced by e-therapy. State licenses restrict providers to practice within a state, but patients on the Internet can reside





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anywhere. This is an unsettled area, so it is smart to take a conservative approach until further guidelines are developed." She advised, "generally speaking, unless there is a specific disclaimer in the insurance policy, the carrier would have difficulty denying coverage for malpractice claims for work within the scope of mental health treatment by a licensed psychiatrist." Therefore, a licensed professional may be covered for liability while practicing on the Internet but geographic scope of practice area is a concern. Grohol however points out, sadly, that licensing boards are infamously inactive in pursuing complaints and taking action against licensed professions. Hfis advice is to practice within professional ethical guidelines and within one's expertise and let case law evolve (Grohol 1999a).

Modalities

Telehealth/Telemedicine

The American government and military interest in the Internet included all aspects of defense including the health and care of personnel in remote areas. Telehealthl Telemedicine is the branch of Internet use and research that provides electronic healthcare to military and civilian populations who lack readily available geographic access to medical care.

E-mail

Therapy via e-mail is currently the most widely used form of Internet mental health service outside TelehealthlTelemedicine, and the most accessible to clients and therapists. E-mail was an after thought of Internet developers who found it convenient to communicate with one another involved in a complex project design. It requires minimal bandwidth and can be accessed with an "appliance" for those who cannot afford a computer. E-mail service can be obtained from several free sources.





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Murphy and Mitchell (1998) developed techniques described above and wrote about their qualitative observations from conducting therap-e-mail on their web site http:/wwteapyInternet.ca. They required potential clients to complete and return an on line form called the Virtually Solve It worksheet, which can be completed off line. They believed that the permanent record of email makes consultation and supervision easier. A response can be reviewed by the supervisor, consultant or peer prior to being sent to the client (p. 26). The permanent potential of email encourages the therapist to be thoughtful and behave in an ethical manner (p. 27). Clients found that filling out the VSI and writing out their interactions with the therapist externalized their problems making them easier to confront and resolve (p. 27). Repeated efforts to obtain this form were unsuccessful, so it appears no longer to be a viable web service, however Grohol's site is active and has pre-therapy form at http://psychcentral.com.

Mitchell and Murphy recommended that further research should be conducted to study the impact and effectiveness of their techniques (emotion bracketing and textual visualization (descriptive immediacy); application of narrative and solution focused therapy in face-to-face and electronic therapy; impact of writing itself in the therapeutic process; and pre-treatment effect of writing to the therapist (e.g., using the VSI)( p. 30) Chat/Conferencing

Suler (1997) describes text talk as austere because it lacks voice, facial

expression, body language and visual/spatial environment. While some may find this disorienting, he suggested that for many, text-talk is a more direct, intimate mind-to-mind communications approximating an internal dialogue. In his study, Suler analyzed manyy megabytes" of saved logs exploring the concerns that the absence of visual and auditory cues confuse users, and lead to painful misunderstanding. He identified





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phenomena of text-based conversation. There is often a lag in live messages due to Internet connection speed. He called these out-of-syn occurrences, temporal hiccups. This can seem similar to talking over another person in face-to-face conversation. The Internet therapist will need to determine whether he or she is viewing a temporal hiccup or an interpersonal issue. Most chat modes providers, including AOL and WEBCT (used in this study), allow for only a line at a time text entry (plus cut and paste for large pieces of text). Correspondents don't actually see what the other is typing until it is published using the enter key. ICQ in live mode however allows for a more natural ongoing conversation limited only by the speed/skill of the typist. Writing is live rather than written then sent. There is software that allows one speaker to complete a lengthy thought before the next message posts and was used extensively in Taylor's AOL Dream Group Therapy.

Suler (1997) developed a convention of "listening". When one person was clearly caught mid-sentence or mid-thought by the limitations of the program, others "need to sit back in a 'listener' mode. Some users will even type "listening to Joe"to indicate this posture to others (p. 5y'. He describes "staccato speak" as a joking around or playful exchange, a group "free for all ( p. 6)." His illustrations are reminiscent of the "Fireside 5" or "Monty Python7 comedy routines ( p. 6). Suler includes acronyms (e.g., brb for be right back) under this category but this researcher tends to see acronyms as more similar to emotions, emotion bracketing and other text talk enhancement. The occurrence of "staccato speak" (minus acronyms) in psychotherapy could signal anxiety or avoidance of painful emotions.





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Barak et al (1999) conducted one of the only empirical studies reported. He and his team chose synchronic chat groups for their research because e-mail, the most common form of Internet therapy,

"lacks a key feature of human interpersonal
communication characterized by spontaneity, authenticity, immediacy and directness. This feature is directly related
to the commonly accepted and generally appreciated
therapeutic factor of here and now. Numerous schools of
psychotherapy argued that this immediacy factor may be
responsible to a great degree for dramatic therapeutic
developments. In addition, defense mechanisms or
cognitive distortions (depending on the school of therapy)
are less likely to take place in a "here and now"' therapeutic
situation. (p. 1)"


In this study of brief Internet Chat room group therapy, Barak. recruited 15

students from several Israeli universities and community colleges. Six participants (three men, three women) were assigned to the Internet condition and nine students (three men and six women) were assigned to a traditional face-to-face group therapy. Both groups were led by experienced, female therapists and were brief, dynamically oriented. One therapist conducted the Internet group while the other conducted the face-to-face group therapy. The Internet condition was conducted in a JavaScript, password protected chat room for seven, ninety-minute sessions. The face-to4ce group met on the campus of the University of Haifa. The dependent measures were Measure of Therapy Impact: SelfEsteem, Social Relationship, and Well-being. Each scale was a 25 item Likert-like scale but Barak does not cite the source of these measures Moose (198 1) developed the group process measure, a Likert-like evaluation questionnaire designed to elicit opinions about the Internet group therapy experience. Because of the small number of participants in





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this study, the data were evaluated qualitatively by analyzing chat room transcripts in addition to reviewing the results of the dependent measures.

Results indicated that participants exhibited positive support, personal disclosures, interpersonal sensitively and group cohesiveness. No comparison with the face-to-face group was reported. Recommendations for further research include a study of preparation for therapist for Internet therapy, and rules by which such groups should operate (Barak & Wander-Schwartz, 1999). Multi-modal

Colon (1994), a prominent social worker, conducted one of the first studies of

Internet psychotherapy. She conducted a three-month study with eight participants using email, chat and bulletin board. Participants were recruited and screening Internet from ECHO subscribers. Participants were screened, refrained from in person contact with one another or Colon, posted/participated actively at least three times a week and participated for three months. Colon's training was psychodynamic and so were her Internet groups. Her primary concern about the experiment Internet groups was the absence of non-verbal cues. (p. 9). She concluded "In Internet therapy, and perhaps in the psychoanalytic session, language is action. Nothing happened Internet, or for all intents and purposes, in therapy. There is no way to quantify what happens in an Internet group. And yet lives can change."

Phillips (1996) qualitatively compared four groups within which she participated, an Internet service Adult Children Of Alcoholics (ACOA) chat group, an Internet service ACOA email list, an Internet ACOA email list and an ACOA chat group she created on the Internet service. None of these groups appear to be formal groups with regular attendance, ground rules and on going interaction as defined by Yalom (1995) whom





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Phillips cites extensively. She reported that each group was roughly organized along the 12-step philosophy. Her discussion indicated that she was a participant in the first three groups rather than a researcher or group leader. She briefly touches on private conversations (JM), cross talk advice giving, and anonymity as assets of Internet groups but there is little research in group therapy to support these as constructive, which she acknowledged, but saw as a positive difference between in person and on line groups.

Suler (2000) complied a list of ten issues to consider in developing understanding in Internet groups and communities. These are general considerations about the uniqueness of the Internet rather than group process constructs. Unidirectional Information Only

Many Internet using therapists are cautiously waiting for legal issues to be resolved and are providing only information, advice, or recommendations, but not psychotherapy. Grohol's forced and constrained definition of e-therapy demonstrates this caution (Grohol 1999b, Grohol 2001), while he is, paradoxically, one of the most outspoken researchers defending the legality of Internet work (Grohol 1999a). Unidirectional information is generally health related articles, electronic journals, and patient information sheets (e.g., WebMD.com, MayoHealth.org).

Guidelines for Ethical Practice of Internet Counseling

The need for ethical guidelines to direct the development of Internet

psychotherapy services was recognized by all major mental health organizations almost as soon as the Internet became commercial. The Health on the Net Foundation published HON Code of Conduct for Medical and Health Websites (HON 1995). Two years later, in 1997, the National Board of Certified Counselors published Standards for Ethical Internet Counseling; and the American Psychological Association published Services by





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Telephone. Teleconferencing. and Internet: A statement by the ethics committee of the American Psychological Associationa). In 1998 the American Medical Informatics Association published Guidelines for the Clinical Use of Electronic Mail with Patients. The American Counseling Association published Ethical Standards for Internet Counseling in 1999. The International Society for Mental Health Internet and the Internet Health Coalition each published their standards in 2000. In 2001, the American Psychiatric Association published American Psychiatric; Association principles for medical ethics with annotation especially Applicable to psychiatry.

In a pilot study, Mitchell and Murphy (1998) examined the email therapeutic

relationship with one client who had engaged in over 100 transactions with the therapists. In 1995, the researchers had set up a pilot counseling site on the local computer bulletin board service. They limited access to counseling services to two thousand members. The services offered were the Virtually Solve It worksheet (VSI) an Internet form design to help the potential client explore and externalize the problem. They introduced therape-mail and Ask PATtYQ, which stood for Professional Answer To Your Question. In 1998 they interviewed the one client chosen for qualitative response to issues being debated by the National Board of Certified Counselors committee on WebCounseling ethics security issues, physical absence, emergency situations, technological failure, therapeutic relationship/efficacy and access. Credential Validating Referral Sites

Reliability, credibility and freedom have been the core values of Internet

developers almost since its inception and certainly, since, it became available to the public. Switzerland is home to two of the primary Internet regulatory bodies, the WWW Consortium and Health On the Net Foundation http://www.hon-ch/ -- @HON. The W3





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Consortium sets voluntary but fairly universal technical standards used in HTML, JavaScript and other development and implementation design tools. @HON, which organized in 1997, sets standards for health and health related web activity. @HON, has a strict, enforced code of conduct in seventeen languages, requiring trained and qualified professionals, support not replacement of traditional care, confidentiality, appropriate credit to source materials, justifiability of products or services, transparent authorship, transparent sponsorship, and honesty in advertising and editorial policy. @HON enforces compliance in several innovative ways. The @HON logo, which is displayed on certified web sites, is "active" or "live". When a web site visitor mouses-over the @HON logo it will link to the @HONcode web site. Non-certified web site designers can copy the logo to their web site but cannot copy the active link. Web users are aggressively encouraged to report any non-active links for @HON team action. The @HON team uses the active link to perform random web site checks. To earn the right to use the @HON active link logo, the web site designer must complete a detailed application and submit to a @HON team examination of the Web site. The applicant must make changes required to come into compliance with HONcode (HON 1995). @HON is recommended by such prestigious American medical organizations as the Mayo Clinic "When you visit a health Web site, look for a logo from the Health on the Net (HON) Foundations. Sites that display this logo agree to abide by the HON Code of conduct. Some sites may choose instead to publish a statement explicitly affirming that they are in compliance with the HON Code of Conduct (Edwards, 2000)."

The International Society for Mental Health Internet http://ismho.org, and

WebPsych Partnership sponsored by ISMHO http://www.ismho.org/webpsych/ are the





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major American based mental health Internet research, development and self regulating organization. Membership and use of the ISMHO logo on a web site is open to any one, professional, consumer or other, who is interested in the development of mental health resources on the Internet; for a modest annual membership fee. There is no site evaluation or monitoring such as @RON uses. The goals of these organizations, however, are not necessarily congruent with those of the professional organizations. For example, the goal of the WebPsych Partnership is "to ensure a high quality of Members' sites and reduce unnecessary competition and harmful in-fighting." In fairness, it does seem to be focused on promotion of web sites and accuracy of web sites rather than interaction with clients or other persons seeking mental health information.

Ainesworth's web site, http://www.metanoia.gx& was organized in 1995 and remains one of the primary resources for information about mental health resources, counselor referral and information. She is a consumer report organization. She adamantly does not hire therapist or market services. Her listings are free, but the etherapist must meet criteria that includes having a web site which she evaluated with @HON standards, communicating personally with individuals, personalizing help to these individuals, and communicating with individuals through the Internet. She will not list any "sites where services are not offered by a credentialed professional psychotherapist."

There is a profusion of sites and listings that do not require professional criteria for inclusion, but do have some criteria. Mental Health Resource with Leonard Holmes Ph.D. purports to be "your guide to over 700 sites"; however, these sites include related professions such as law and unrelated topics such as aliens. The criteria to list with this





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site indicated that a web site "should not be used to advocate or promote the following: any illegal activity, activities that support or espouse non consensual and/or extreme violence or sexual aggressiveness toward another individual or group for any reason, activities that support or espouse hatred towards another individual or groups based on any criteria and activities and input from individual that violate our inclusive standards http://mentahealth.about.gom ." While these are laudable criteria, they fall short of mental health professional practice criteria.

Clinician's Yellow Pages htt://mentalhelpnet/mhn/yellowags ; hosWoi Mental Health on the Web http:/fidealistcomtwwmhw/c Find-a-Therapist; and 1-800Therapist; list web site for an annual fee, without evaluation or monitoring, similar to a listing in the Yellow Pages of a telephone directory.

Basically, a psychotherapist practicing on the Internet must establish all the same security, authenticity, and grievance procedures as the psychotherapist seeing clients in a physical office. A physical office has a pleasant, soothing decor, locks on the doors, security system, secure location and procedures for charts, requests for notes and so forth. In physical office, a therapist must display, at minimum, the occupational license and the professional license to demonstrate authenticity and grievance resources. The virtual office needs an effective web site that is uncluttered, appealing, and easy to navigate. There must be firewall(s) protecting the therapist's computer system, SSL across the network and easy instructions for client firewalls (locks on the doors). Authority to practice is demonstrated by posting live logos (i.e. licenses) for security (e.g., Verisign) and credentials (e.g., @HON). Live logos are linked to the company and the client can instantly verif the therapist's legitimacy to the extent of each authoritative body's





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responsibilities. No one denies that these technologies are cumbersome and may well cause therapists to think twice about practicing on the Internet or incline some therapists to practice without adequate safety precautions. Advantages of Internet Counseling

The perceived advantages of Internet Counseling are it's immediacy, availability, anonymity, and economics (Brown & Walz 2000, Fink 1999, Grohol 1999b, Grohol 2001, King & Moreggi 1998, Patterson 2000, Stubbs 2000). Internet access is immediate, any day of the week, any time of day, any where in the world. One does not have to wait for business hours or for an appointment. The Internet users in search of information, companionship, and advice to get through a sleepless night, pain, or spasms can readily find help in a chat room, bulletin board or informative web site. The Internet is available in many remote geographic areas where users do not have access to therapists. It is available to situationally remote users include home bound care-givers, the elderly, persons with disabilities, and those who would be at employment or social risk from seeking counseling. The Internet can be anonymous. Personal information (age, gender, ethnicity, physical condition) can be disguised. Web counseling is considerably less expensive than traditional face-to-face counseling. The overhead of maintaining a web counseling site is much less than that of renting office space, maintaining a staff, occupational license, fur-niture and equipment, the myriad of taxes, and other "cost of doing business" in the traditional setting. Owners of the PsychOptions site htp://www.psychoptions.com/raters & tyes -of services.htm, for example, lists the following charges: One question/one problem $25; One e-consultation/first on-going session $50; On-going session $35; Telephone session $50 for 50 minutes. The one question, e-consultation and on going sessions are all conducted by email. The





46


PsychOptions site offers a sliding scale "If you have extenuating circumstances and/or are over 65+ and/or on a fixed income then you may contact PsychOptions to request an adjustment and explain the reason why."

Disadvantages of Internet Counseling

Internet counseling is a double-edged sword. The disadvantages of Internet

counseling can be the same as the advantages -- immediacy, reliability and validity of information, security (e.g., privacy and confidentiality), anonymity, abandonment, physical absence, ethics, legality, and security (Grohol 1996, Storm & Moreggi 1998, Oravec 2000). While a potential client may be assured of a response within 48 hours while a non-crises office client may have to wait a week or two for a first appointment, the quality of that first contact may be no more valuable than the first phone calls to a physical office and responses appropriately provided by trained office staff. The credentials of the Internet counselor may be as valid as those of the office counselor; however, it is generally more difficult to verify those credentials as demonstrated above in the extensive discussion of web security. In a traditional office the client can examine see the professional license and the business license, both of which are required by law (at least in Florida) to be prominently displayed. The local Better Business Bureau and Chamber of Commerce can both be contacted to check the counselor's business history and can offer recourse if problems arise.

As discussed above the web is developing comparable resources in @HON and Metanioacom, however they are not well known. Furthermore, in a physical site, the client has recourse if credit card charges, personal checks and cash payments are mishandled. Again the Internet offers security but many sites promise security (e.g.,, affordablewellness.com) when in fact they are not secure. Buyer beware is never more





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true than in the Internet environment. PayPalcom acquired by Amnazon.com in July 2002 offers some of the same financial recourse as services continue to evolve in the credit card industry as e-commerce grows. Unless the URL begins with https (hypertext transfer protocol secured), the site is not secure. Unless there is a small padlock icon on the status bar of Internet Explorer or Netscape, the site is not secure. Again, many consumers, especially in a time of stress or crises precipitating contact with a counselor, may not be aware of these Internet conventions. To avoid the expense of a secured site, many small merchants ask that credit card numbers be emailed to the site. Email can be secure but again, if it is, there is evidence of that security that clients are unlike to know or consider in a time of distress. Does Internet counseling provide privacy and confidentiality both in personal information and financial information? It can, but many sites do not.

There is often legitimate concern in physical counseling rooms about thin walls, crowded waiting rooms, and non-counseling staff access to chart notes. There are, however, analogous problems in a cyber counseling room the client's own family or co workers may have access to the screen as the client "talks" with the counselor or to the records in the computer. A spouse seeking a contested divorce, a vindictive co-worker and other persons with agendas harmful to the client may be able to print off logs of the sessions, emails, or bulletin board postings. Clients, computer end users, may or may not be aware of what is recorded in the computer program itself A client can conscientiously protect his or her email correspondences, and yet never know that the chat session is automatically being saved by the computer software. The client's own associates may have more access to the very information that the client needs to have secure from others.





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Another disadvantage is face validity on the Internet. A well-designed site may have powerful face validity that speaks volumes for the competence of the web designer but say nothing about the credentials and skills of the counselor. With a population accustomed to visual pleasure from screens television, movie, electronic games, and computer monitors, the design may allow totally unqualified, perhaps even harmful counselors" to garner large "practices". What you see, may not be what you get.

Anonymity, abandonment, and physical absence are closely related. The client and the therapist for that matter can disguise his or her identity on the Internet. This reality needs to be built into Internet counseling theory as the modality evolves beyond applying traditional modes to the new media. The client could also disguise his or her identity in person although it is more difficult if payment involves insurance policies or credit cards. Abandonment is a serious risk on the Internet, while it less likely to occur in a physical practice setting. Traditional clients may feel abandoned when their treatment is completed, when they are referred to another mental health care provider when these issues required different skills or training, or, in a clinic setting where the counselor turn over may be high; however physical sites rarely "just disappear" the way web-sites do. Some argue that no interpersonal bond in the cyberspace can replace actual physical presences (Plant, 1996).

Cognitive Behavioral Counseling Models

Cybercounseling is not limited to one or a few theories or therapeutic models of counseling. Researchers have studied family (Oravec 2000), self help (Storm & Moreggi 1998), group (Barak & Wander-Schwartz 1999, Colon 1994, Suler 2000), and brief cognitive (Edelstein 1996, Palmer & Ellis 1995, Ellis 1996), therapies conducted in cyberspace. This study, however, will apply the brief cognitive behavior therapy model





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because it is best suited to the participant population, personal growth issue-focus and alliance development. As such it provides a model appropriate for 3-session, personal growth focused study conditions.

Cognitive Behavior Thera4py

Cognitive Behavior therapy grew out of the work of social learning theorists

including Lewin, Bandura and Lazarus. Prominent researchers in this important area of theory and therapy include Ellis, Miechenbaum, Beck, Burns, Marks, and Rush. Miechenbaum (p. 179-198) describes the process of therapy as involving three mental constructs he calls cognitive events, cognitive processes, and cognitive structures. His theory links these cognitive constructs to emotion, behavior and logical and natural consequences of those behaviors. Cognitive events are conscious, identifiable and readily retrieved thoughts, images and feelings. They include appraisals, expectations, attributions, self statements, automatic thought and internal dialogue. The person experiences them as spontaneous, and rarely questions them. These events occur when an individual is trouble shooting a problem, uncertain about an action or choice, and when a routine behavior is blocked requiring an alternative or creative solution. Cognitive processes are the mental processes by which we acquire information, store it in short term and long term memory, appraise information, filter it, and recall it. Meichenbaum identifies three cognitive processes that lead to emotional distress confirmatory bias, mental heuristics and metacognitions. Confirmatory bias is pre conceived notions or ideas that function as fact. Mental heuristics in the habit of selecting experiences or information that confirm pre-conceived biases. Meta cognition is the ability, knowledge or skills to be aware of and control ones own cognitive processes. The process and goal of cognitive behavior therapy is to educate the client in recognizing his or her cognitive





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events, cognitive processes and meta cognition. Cognitive templates or schemes are identified and the client is enabled to change those templates that no longer function in his or her best interest. Meichenbaum encourages the client to be his or her own "folk" scientist and assigns experimentt' to develop needed skills. He encourages therapists to use specific examples to identify faulty logic "We have found that people often make certain kinds of errors in the way they look at situations and that these errors in thinking may contribute to arriving at premature or incorrect conclusions. It's natural to readily come to such conclusions without even noticing them (p. 193)." Logical errors include all or nothing thinking, seeing possibilities as certainties, dichotomous thinking, personalization and self blame for negative events, and over generalization. Because this theory and therapy relies on homework and experimentation by the client to reach his or her own conclusion, that affect change, it is adaptive to an Internet Counseling environment,

Gabriel & Holden (lecture reported in Laszlo 1999) developed an Internet

protocol for cognitive behavioral therapy, that looked at theme patterns in text based sessions. They sough patterns of over generalization as indicated by the use of polar adjective, excessive self attribution of responsibility, minimizing or maximizing significant issues, and focusing on negatives (p. 296-297). There does not appear to be further information on their theory or research but it is intuitively practical.

Ellis developed Rational Emotive Therapy (REBT) in 1955 and changed the name of this theory and method to Rational Emotive Behavior Therapy in 1993 to include the Behavioral component of change, which had always been present in his theory (Ellis 1998). He posited emotional and behavioral problems have their source in faulty





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thinking or irrational beliefs. His ABC model has grown alphabetically over time but still focuses on an Activating event, some event at work, home, or interpersonally that triggers the emotional crises or Consequences. The client experiences the Consequences with or without being aware to the triggering event and generally without being aware to the irrational, rigid Belief that connects a triggering event to the emotional or behavioral consequence. In REBT, the irrational Belief is Disputed using cognitive skills introduced by the therapist but practiced in homework by the client. The outcome is Effective and Efficient responses to would be Activating events. Ellis identified eleven irrational beliefs that cause the gamut of emotional problems.

Some of the websites established by founding CBT therapists are located at Aaron Beck, M.D. h-ttp://www.beckinstitutt.org; David Bums, Ph.D. http://feelinggood.com ; Albert Ellis, M.D. Http://www.rebt.or ; Isaac Marks, M.D., http://www.thisiswdtshire.co.uk/; Donald Meichenbaum Ph.D. http://www.arts.uwaterloo.ca; and A. John Rush, M.D. http://www3.utsouthwestem.Ou/pUchiatU/facbios/rush.htm/ Brief Cognitive Behavior Thg@Vy

Ellis (1996), Beck (1979) Bums and Meichenbaum (2000) have each researched and developed brief cognitive behavior therapy protocol some of which are as brief as one session maximum benefit. In a World Counseling Network forum Ellis (1998) describes REBT as "designed originally because psychoanalysis and most other forms of therapy were very long winded. So I tried to devise a system that would understand the core beliefs, the core irrational beliefs of the clients very quickly and help them to get to work to dispute them and debate them in a short period of time. So in a sense REBT was on to the few therapies designed to be brief (p.2)." In reply to a question about efficacy





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of short term therapy, Ellis mentioned that "at least 1000 empirical studies ... tend to show that short term therapy at least when it is done with CT or REBT definitely is as effective or more effective than other kinds of therapy and more effective than the therapy that is given to control groups (p. 4)." He further cautioned White, de Shazer, Watz1awick and other brief therapy authors that they "had better not use the generic term 'brief therapy' to imply that they are the only form of brief therapy.

Ellis (Palmer & Ellis 1995) was trained in psychoanalytical therapy but realized that it takes "a fairly long time to get people to free-associate, analyze their dream and go over and over their childhood and later historical material." He describes his early work as psychoanalytically oriented as opposed to classic psychoanalysis. "I found out, to my surprise ...that it was better, got better result than classical analysis... you quite quickly get their basic history (p. 68-69)." He continued "REBT is intrinsically more efficient and briefer. Often during the very first session I can show people the ABCs of distress... So REBT is sometimes successfully done in a few sessions (p. 69)."

In his book on brief therapy, Ellis (1996) affirmed that REBT can be

accomplished with self help materials including books and cassettes that teach the REBT principles Edelstein (1996) advocated three minute REBT sessions applied twice a day focused on Ellis' construct of "musty thinking". He demonstrated that one session can be sufficient to teach the principles of Rational Emotive Behavioral Therapy and involve the client in three-minute techniques. In the forward to Edelstein's book, Ellis, founder of REBT, says "Of course it takes significantly longer than three minutes to dislodge the many dysfunctional aspects of a troubled personality. But the clear and simple exercises advocated by Dr. Edelstein, exercises, which are totally consistent with my principles of





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Rational Emotive Behavior Therapy, can be practiced in three minute segments, to be repeated several times a day."

Wood (200 1) describes the typical CBT length of treatment as brief "One of the major features of CBT is the relatively short time fi-ame required for change to begin. Some "brief interventions" were developed using the CBT approach for a one-time, several minute session (suitable for application by generalist health workers such as nurses and general practitioners). She emphasized that even when these extremely brief sessions are not used, CBT rarely requires more than 6-12 months, which would include scheduled follow-ups for gain maintenance and stabilization.

Brief therapy mandates that a therapeutic relationship develop quickly, therefore numerous researchers emphasis the need to carefully select high functioning clients who have a high level of interpersonal functioning. Seriously-ill clients should be referred for long-term therapy where development of the interpersonal relationship can be the focus and goal of therapy. (Safran & Muran 1998) These authors recommended that early priorities in brief therapy should be to develop the therapeutic bond with warmth, respect and genuine interest, reminiscent of Rogers. They offered that the therapeutic rationale, the goals and tasks needed to accomplish that goal, should be laid out in the first session. They summarize their recommendations metaphorically as "part Marcus Welby and part Sherlock Holmes."

Using Brief Th-eraM with Un-dgergmdmates

It seems reasonable to assume that most college students are high functioning by virtue of meeting admission criteria and remaining in an environment that requires selfcare and executive functioning. Those who are not high functioning will quickly come to the attention of the resident advisors, concerned friends and faculty, or the crisis center





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and be referred for appropriate care or encouraged to return home for care. This is not to suggest that college students do not have serious mental health issues and concerns but rather that they are most likely to have the personal talents and resources to maintain functioning through personal crises and while seeking counseling services available. Wilson (1978) addressing common developmental problems of career direction, sexuality, belief clarification and separation from parents, went so far as to suggest classroom and resident hall intervention would provide cognitive interventions by providing problem solving development. Archer and Cooper (1998), Pinkerton and Rockwell (1994) and Steenbarger (1992) have applied the tenets of brief therapy to the target population of this study. Although each of these researchers found that there is resistant on the part of colleagues to endorse brief therapy, their research and the research of others fbund brief therapy "to be both effective and efficient in campus counseling and mental health counseling.

Luckey (1996) and Christmas (2000) addressed the use of Internet communication modalities with college students. Indiana University of PennsylvaniaUniversity Health Services (Luckey 1996) used the Internet for communication and data base processing. Because this work was written early in the public access to the Internet, its application appears to be limited to communicating with and retrieving data from colleagues rather than direct student services. However, four years later, Duke University (Christmas 2000) was using unsecured E-mail (password protection only) with the student body population and had established guidelines for interaction with students by email. These guidelines specify the exclusion of "sensitive' information that North Carolina state law requires a health care provider to present to a client in person (e.g., positive HIV lab





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results, pap smear results, worker's compensation information, and some prescriptions). It does not appear that Duke University student health services were providing counseling services via the Internet; however the guidelines do not seem to exclude such use as long as topics precluded by state law from remote access were not discussed. It is significant that Duke University was not using an encrypted site. Undergraduate Persnal Growth Concerns

University administrators, entrusted with the education, safety and well-being of hundreds of thousands of young adults, many of whom are away from home for the first time, have needed to know the kinds of stressors, issues, problems and concerns typically manifested on a college campus. Murphy and Archer (1996) identified thirteen academic stressors and fifteen personal stressors in a survey of 639 students attending the same university as participants in this study. Academic stressors confirmed by a significant number of respondents included tests and finals, grades and competition, professors and class environment, studying, finances, papers and essays, speaking in class, and others. Personal stressors confirmed at a significant level were parental conflicts and expectations, finances, interpersonal conflicts, judgment and acceptance by peers, personal achievement and goal setting, approaching and meeting other students, general adjustments to change, personal appearance, current job, and other. The "other" category allowed students to include stressors not mentioned in the survey. The most frequent 4tother" was not getting enough sleep, followed by finding time to get everything done. Other statistically significant stressors were family member illness or injury, personal health, and pledging. These are the types of issues thought to be appropriate for personal growth sessions conducted during this study. The study illustrated that while the rank order of problems changed from 1985 to 1993 changed, the categories remained the





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same. The same is assumed to be true between 1993 and 2002; however it recognized that the wide spread access to the Internet, the university requirement of personal student ownership or ready access to computers, the use of Web based and distant learning and the events of 9/11/01 may have generated new categories of concern not relevant in 1985 or 1993 although no such new categories were observed in the present study.

Individual Information Processing Differences

Many factors have been demonstrated to influence how individual process

information such as therapy input and tasks results. Some of these include environmental and cultural variables such a race, gender and ethnicity, brain lateralization with emphasis on processing information verbally or with images, and personality traits including introversion and extraversion.

Demogaraphic Factors

The major premise of the huge national investment in Telehealth/Telemedicine is that technology provides a method to reach under served populations -- women, undereducated citizens, rural citizens, Native Americans, citizens with disabilities, and citizens of color (HCFA 1996, HCFA 1999). The concern of researchers (Reid 1994, Powell 1998) is that the price of technology, and the education and experience required to uses these resources may effectively exclude the very populations it is thought to most be able to benefit. Powell (1998) found that the majority of Internet therapy users were male.

Learning Style Theory

Learning style, brain lateralization, and information processing research and

theory have contributed a substantial body of information indicating that people encode, process and retrieve information in distinctly different manners. Two style systems are of





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interest to the present research, academic oriented learning styles and temperament based learning styles. Academic learning style theory addresses specific skills and tasks generally incorporated into formal pedagogy. Temperament based learning styles affect how the individual learns formally or informally by his or her inborn nature and traits. Academic Learning Styles

Of the researched styles, verbal, visual, kinesthetic, group, individual, oral

expressive, and written expressive (Babich, Burdine, Albright & Randol 1976), the most consistently identifiable and validated styles have been visual and verbal (Lazarus 1964, Richardson 1969, Richardson 1977, Delaney 1978, Dyckman & Cowan 1978, Akins, Hollandsworth, & O'Connell 1982, Akins, Hollandsworth, & Alcorn 1983, Pavio & Harshman 1983, Maclnnis & Price 1987).

Richardson (1969) cites a late 19th century researcher, Lay, who illustrated his concept of the misunderstanding among people as being a result of learned or innate preference for verbal processing or visual processing with the historical animosity between Greek philosophers Socrates who "heard the voice of his daemon" and Protagoras who thinking and debating relied upon visual/kinesthetic processes. Richardson quotes Lay as saying "if one is auditory-linguistic he should never enter into an argument with a motor-linguistic person, as on all topics except the most concrete facts, either will inevitable fail, completely, to understand the other (p. 83)." The preference many mathematics students have for either word problems or equations is a relatively common example of the encoding, processing and retrieval impact of verbal processing or visual/symbolic processing, respectively. Lazarus (1964) deemed visual processing to be a crucial factor in systemic desensitization therapy. Now, nearly 40 years later, the question must be asked if the ability to visualize a virtual counseling





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environment is an individual difference in the ability to developed a therapeutic working alliance and produce a satisfactory therapeutic outcome. As potential clients are evaluated for cyber counseling, should their preference for verbal processing or visual processing be considered?

Visual Learners

MacInnis and Price (1987) summarized the role of visualizing in marketing as "a processing mode in which multisensory information is represented in a gestalt form in working memory." The visualizers were found to use daydreams and fantasy in addition to graphically and pictorial representations in problem solving. Babich (1976) operationalizes the visualizing construct as the preference or ability to learn from seeing words or numbers and remembering spoken information by writing it down. Richardson (1983) found that the visualizer's thinking processes consisted of pictorial or visual images. The visualizer attended to the spatial layout, physical features, and sensory input of information to be encoded. Verbal or Auditory Learners

Babich, Burdine, Albright & Randol(1976) operationalized the verbalizing

construct as a preference for hearing words or numbers spoken and noted the common practice of verbalizers to vocalize or move the lips or throat while reading written materials. Richardson (1983) found that verbalizers' thinking processes consisted of spoken words or self-verbalizations, that is, linguistic encoding, labeling or naming. He likened it to an experience of inner speech.





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Temperament Learning Styles

A second widely used learning style indicator has been developed by educators using the MBTI temperaments (rather than types). The learning styles are SensingPerceiving (SP), SensingJudging (SJ), iNtuitingThinking (NT) and iNtuitingFeeling (NF). Dean (1997) noted that these four personality were recognized as early as 450 B.C.E. These four temperaments are found in the sixteen types associated with the. Gallagher (2002) describes people with the SJ temperament as guardians of tradition or traditionalists, learning from the past. People who prefer to use the SP functions are artisans and experiencers who learn best from their own work and experience. People who draw primarily upon the NT functions learn best conceptually looking for rationale, explanation, theories and hypotheses. People who depend most strongly on the NF functions are seen as idealists and learn inductively. Sensing Perceiving

Dean (Dean, 1997) proposed that people using the SP function combination or temperament are similar to those C.I.T.E. describes a kinetic tactile, preferring hands on and active learning situations, which offer the opportunity to construct, operate and manipulate objects.

Sensing Judging

People using the SJ learn best when their classroom, counseling environment, or other learning situation provides clear expectations and a "right way" to do things. Clear directions, specific extra-therapy assignments and an overtly structured session are valuable assets to learning for those using the SJ functions





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Intuitive Thinking

People using the NT style learning well from long-term independent projects,

experimentation, inventions, and complex problem solving. This style is somewhat similar to the visualizer and group independent style. Intuitive Feeling

NF users need cooperative personal relationships and learn best in a friendly atmosphere. They do not do well in rote, non-democratic environments. They prefer ideal relationships and excellent interpersonal communication skills somewhat similar to verbal or auditory learners.

Learning Style Conepualiato Cmarison

It should be noted that although there are some similarities between the C.IT.E. learning styles and the MBTI learning styles, they are not redundant and each offer a different perspective on learning. Designed for the classroom, the C.IT.E. learning style taps actually educational activities preferences in its items and classifications, while the, based on the broad Jungian theory of personality and temperament, is more generalized and perhaps more applicable to life long learning in an educational format and well as in life in general learning. Therefore, both measures were used as independent measures in this study.

Measuring Information Processinag

Richardson (1977) developed the Verbalizer-Visualizer Questionnaire 'to access the extent to which one's thinking processes consists of words or self verbalization versus pictorial or visual images." It consists of 15 forced choice items adapted from Paivio's





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86-item Ways of Thinking Questionnaire. The questionnaire was normed using junior high school students.

While Richardson examined information processing in social psychology, education psychologists Babich, Burdine, Albright and Randol (1976), developed a learning style inventory, which is widely used today. They targeted three areas of concern information processing, work conditions and expressiveness preference. It is the information processing visualization, verbalization that parallels the social psychology work. Items were drawn from the same source material as the Visualizer Verbalize Questionnaire, has more extant reliability and validity data, is published and readily available, and has been used extensively in education, adult education, career counseling and vocational rehabilitation. The Center for Innovative Teaching Experience Learning Style Inventory (C.I.T.E.) is used by the Veterans Administration and public school districts across the country to identify learning styles and to guide instructors, counselors and teachers in designing learning experiences to maximize the students-- use of their preferred learning style. The West Virginia Adult Basic Education program uses the CITE as its primary assessment instrument to guide recommendations for tutorials, adult learning experiences, and vocational training.

Myers and Briggs (1962) developed an extensively studied, widely used

assessment tool, the Myers Briggs Type Indicator (MBTI) to measure the individual's trait preferences consistent with Jung's theory. There are four independent dimensions, introversion/extroversion; sensing/intuititing; thinking/feeling and judging/perceiving. Interpretation of the "type" involves hypotheses about the interactions of these dimensions and involves understanding of dominant functions, auxiliary, inferior





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functions, and so forth. The result of an MBTI is one of sixteen types that purport to describe a person's inherent functioning and are used to help people understand why others respond differently in the same situation. Keirsey and others have focused on temperament grouping and developed their own variations on the MBTI; however, the MBTI was used for this study because it provided both the learning style data and personality trait data discussed below.

Personality Attitude

Except for those clinicians who practice radical behavioralism, individual traits play a prominent role in the planning, conduct, process and outcome of psychotherapy. Jung (1923) was once of the earliest psychiatrists to postulate personality types. He identified polar attitudes that he called introversion and extraversion. In the MBTI user's manual, Myers (1962, p. 9) describes extraversion as a trait or attitude of people who "like to focus on the outer world of people and activity. They direct their energy and attention outward and receive energy from interacting with people and from taking action." She describes introversion as an attitude of people who "like to focus on their own inner world of ideas and experiences. They direct their energy and attention inward and receive energy from reflecting on their thoughts, memories, and feelings." Eysenck (1970) suggested that personality is biologically determined and is arranged in a hierarchy consisting of types, traits, habitual responses, and specific responses. Eysenck built upon Jung's theory with empirical research, describing a structure of personality along three dimensions, one of which was introversion-extroversion. Brinegar (1992), researching the predictive value of the MBTI in counseling outcome found that "extraversion-introversion dimension surfaced as the only single dimension score to be significantly correlated with counseling outcome." Myers, as early as 1962, suggested





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implications for counseling based on type and counseling goal vocational and career, education and learning, organizational team building and provides guidelines for using introversionlextraversion (as well as other scales) appropriately in each setting. Introversion

The trait of introversion is generally associated with a preference for

communicating in writing, working out ideas by reflecting on them, being private and self contained, and for taking the initiative when a situation or issue is very important to the person (Myers 1962).

Extraversio

The trait of extraversion is seen in people who are attuned to their surroundings, communicate verbally, problem solving by talking through issues, and learn by doing or discussing (Myers 1962).

Measuring PersonaliV Attitud

While Jung, Briggs, Myers, and McCaully all thought and taught that the

dimensions are dichotomous, several researchers (Mendelson 1965, Girelli & Stake, 1993) examined the wales as continua and suggested that the forced choice format of the forces the bipolarity artifact, underestimating the true continuum of the dimensions. The current protocol for scoring the MBTI has keys for calculating the degree of introversion/ extraversion for example rather than regarding them as dichotomous categories. For the purpose of this study, the scales were treated as discrete traits.

The dimension relevant to this study is Introversion/Extroversion. Livingood

0 995) found that "the number of introverts on these (Internet mail lists by MBTI type) is five times greater than the number of extroverts. However, in the United States at large,





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introverts are a minority group comprising only 25-30%/ of the total population. (p. 8)." While intriguing, this may be skewed by the obvious fact that the mailing lists are presumably drawing from a world population rather than a US population. Livingood himself writes from Australia. This perception may also reflect the observation that the people who first had access to the Internet and continue to have predominate access to the Internet are engineers and scientists who make up that 25%-30%/ of American introverts (Myers 1982). The use of the introversion/extroversion scale in this study is significant because the study population is United States citizens or international students choosing to study in the United States. The participants were recruited from the College of Education rather than engineering or science.

Counseling Process an Otcm

During the first half of the 2&~ century, researchers primarily focused on

understanding the psychological processes that affected the well being of the population. This research generated the great theories of personality and the applied therapies have helped people enjoy a better quality of life for three generations. In the second half of the century, researchers began to examine how the therapies produced the results that were anecdotally abundant. They examined what factors conditions and environments that increased or decreased the efficacy of therapies. Financial accountability in government health care service has driven research in outcome efficacy and consumer satisfaction for the past two decades. In the mental health field, this research has taken two primary directions, efficacy of the counseling process, the helping relationship, (Gaston 1991, Greenson 1965, Hartley & Strupp 1983, Alexander & Luborsky 1986, K~ee, Abeles, & Muller 1990, Kobotovic & Tracey 1990, Horvath & Symonds 1991, Horvath, Gaston & Luborsky 1993, Horvath & Luborsky 1993) and efficacy of the over all experience,





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consumer satisfaction (Becker et a]. 2000, Cialo 1982, Eisen, Leff', & Schaefer 1999, McCullough 1993, Preston 2000, Treadwiell, Soetikno, & Lenert 2000). Working Alliance

For several decades,, researchers have attempted to isolate the therapeutic method or technique that was most effective. This research had limited results when the broad concept the interpersonal milieu of therapy, first introduced by Freud as transference

- was examined. Clarkson distills from the literature and her diverse theory training, five relationships between therapist and client, which strongly inform this study. Although not all these relationships may exist in any given therapeutic relationship, and may not be recognized by all theoretically orientations, each is potentially available within computer-mediated therapy as in the face-to-face work, however it was the first, the working alliance, with which this study is primary concerned. Identified therapeutic relationships include

"The working alliance as the part of client-psychotherapist relationship that
enables the client and therapist to work together even when the patient or client
experiences strong desires to the contrary.

The transferential/countertransferential relationship as the experience of
unconscious wishes and fears transferred on to or into the therapeutic partnership.

The reparaive/developmentally-needed relationship as intentional provision by
the psychotherapist of a corrective, reparative, or replenishing relationship or action where the original experience was deficient, abusive or overprotective.

The person to person relationship as the real relationship or core relationship as
opposed to object relationship.

The transpersonal relationship as the timeless facet of the psychotherapeutic
relationship, which is impossible to describe, but refers to the spiritual dimension
of the healing relationship. (Clarkson, 1995)"





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To measure the presence and relative weight of these constructs research teams at the University of Pennsylvania developed the Penn Helping Scale (Alexander & Luborsky 1986); at Vanderbilt, the Psychotherapy Process Scale and the Negative Indicators Scale (Suh, Strupp, & O'Malley 1986); and at Simon Fraser University, the Working Alliance Inventory. (Horvath & Greenberg 1986). These projects all based their work on the Bordin's (1976) three-factor operational decimation of the helping, therapeutic, working alliance that consisted of interpersonal bond between the client and therapist. This is transferencelcounter transference without a pathological implication. Bordin further suggested the need for agreement between the client and therapist as to the goal of therapy and agreement as to the tasks required to accomplish this goal. From 1976, Bordin maintained that, to be effective, the therapeutic relationship must be collaborative, not hierarchical.

Measuring Therapy Outcome

Outcome evaluation has evolved from early opinions of the therapists, to complex testing using instruments including the MMPI (McCullough 1993), to semantic differential studies designed to cover all possible theories available and obfuscate the purpose to the measure to avoid contamination (Stiles 1980), to market driven consumer satisfaction surveys (Patterson & Leach 1987). Therapist opinion may be highly accurate or may be self serving in any given situation. A structured form of therapist opinion has been developed and formed over four decades and five versions of the Diagnostic and Statistical Manual. (DSM). The Global Assessment of Functioning (GAF) (APA 1994) is the most widely used outcome measure because it is the Axis 5 measure, required as part of the five-axis mental health diagnostic report. Its use has been increased by the demand of most HMO's and PPO's for use of the five-axis system.





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The origin of the GAF is the Health Sickness Rating Scale (HSRS) developed in 1962. It consisted of thirty case studies and seven scales "ability to function autonomously," "seriousness of symptoms," "degree of discomfort," "effect on environment," "utilization of abilities," "quality of interpersonal relationships," and "breadth and depth of interest." A single score results as is true for the GAF. These scale concepts can still be identified in the descriptions of the levels of functioning in the GAF. The Global Assessment Scale (GAS) was a simplified form of the HSRS and has a.9 correlation with the HSRS. The GAS more closely resembles the GAF, in that it no longer has scales or case studies. The descriptions illustrate each I 0-point range on a scale from 0 to 100. The GAF was identical to the GAS except it had a range of 0 to 90 in the DSM-M-R, however the scale has been returned to 0- 100 in the DSM-IV. (McCullough 1993). Other recommended instruments to be included in a "core battery" are the Beck anxiety and depression inventories, the Hamilton anxiety and depression rating scales, the psychiatric status schedule, the social adjustment scale, the HealthSickness rating scale, the MCMI, the Wisconsin Personality Disorders Inventory and such. These measures however are more appropriate to a clinical population that allows a statically significant range of change. Nations such as Australia and New Zealand who have social health care have conducted extensive outcome scale development and utilization studies (Eisen et al. 1999, Preston 2000). While these instruments are much more concise and economical than the battery of tests recommended by McCullough, they are again more geared to the outcome of clinical populations.

Consumer satisfaction is a business and marketing concept, which seems to have entered the health care environment with managed health organizations. Employee





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Assistance Programs (EAP), social work and rehabilitation counseling seem to be on the leading edge of development of these instruments, however, reliability and validity has not been rigorously demonstrated. The consumer satisfaction survey is, nonetheless, the most appropriate outcome measure for this study of undergraduate students presenting with developmental and growth issues. Attkisson et. al (1982) developed a college student satisfaction form that was too specific in it items and too long (82 items) to be used in this study.

An outcome satisfaction questionnaire was developed for this study using the work Dansky, et al (1996) as a guideline. The items developed were submitted to a committee of experts (e.g., Delphi Method for evaluation and were used by counselors and students in a pilot study at a local community college. Counselors and students were asked to respond to each item based on their experience at the counseling center and to offer content, wording, and face value feedback regarding each item. The resulting instrument consisted of two forms, one for participants, and one for facilitators. The participant form had 12 items, seven Likert-like items about satisfaction with the personal growth sessions outcome, two Likert-like items assessing the participant's self perceived computer competence, and one Likert-like items eliciting the participants' predicted future uses of computer-mediated counseling. Two items were open-ended qualitative questions requesting the participants' opinions about the personal growth sessions. The computer-mediated aspect was specifically targeted in the qualitative questions to allow the participant to appraise his or her experience regardless of assignment to conditions of the experiment. The facilitator version had similar session focused items but did not have the qualitative items, the computer competence items, or the predicted future use items.





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This information was collected in personal interviews with the facilitators after they had completed their all of their sessions with participants.

Anlication in this S

The goal of this study is to contribute meaningful research to under-gird and advise the developing phenomena of Internet counseling. The foundation for good counseling has been developed over the past century and for good communication over the past many millennia. The advent of a new venue for communication and the willingness of mental health professional to move out into this venue should surprise no one. As counselors bok-fly go where no one has gone before providing mental health services in cyberspace, research asks What is known about the new environment? What needs to be known? What risks can be anticipated? What risks cannot be anticipated? What known tools can be used as is? What needs to be retooled? What new tools need to be invented? No one study begin to answers do all that, of course. The purpose of existing professional literature is to suggest answers or directions to answers for some of these questions.

It seems clear from the literature that a rich very human culture has developed on the Internet over the past 30 years, initiated by graduate students at MIT, Stanford and 7 other prominent universities, who were given carte blanc to "see what could be done" with the new technology. Government initiates to provide health care to citizens in geographically remote areas and the commercial emergence of Internet use have paved the way for cyber-counseling. Cyber counseling appears to lend itself to brief therapy with non-crisis clients. Several years of cyber counseling practice have created a need for research to determine the efficacy of cyber counseling and to suggest predictive criteria for screening potential clients for appropriateness for cyber counseling. Many





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questions need to be explored. There are several technologies that can be used virtual reality, web-cam live transmissions, individual written messages (email), public written messages (bulletin boards), and live written messages (chat rooms). The Internet lends itself to group interaction, but individual intimacy is also well represented. The scope of this study was confined to individual therapy in a live (synchronic) written format. The individual differences the participant brings to the personal growth computer-mediated sessions were compared to those that they bring to traditional face-to-face sessions.












CHAPTER 3
METHODOLOGY

Statement of RMose

The purpose of this study is to examine the efficacy of Internet counseling. Chat room counseling was compared with traditional face-to-face counseling. Similarities and differences were measures for therapist-participant alliance and for outcome. Four of the multitude of individual differences, gender, ethnicity, personality, and information processing, that each participant brings to the therapeutic setting, were measured to determine is any difference in impact can be discerned in the face-to-face or computermediated condition. This chapter presents the research hypotheses, dependent and independent variables, sample population, procedures for training the facilitators, procedures for the implementation of the personal growth sessions, instrumentation, experimental conditions and assignment to conditions, data collection and statically analysis.

Hypotheses

The study will test the following null hypotheses:

Hol: There is no significant difference in the client reported quality of the
working alliance when counseling is delivered face-to-face or computermediated regardless of gender, ethnicity, personality style, learning style.

Ho2: There is no significant difference in outcome efficacy when counseling is
delivered face-to-face or computer-mediated regardless of gender,
ethnicity, personality style, or learning style.

Ho3a: There is no significant relationship between the client reported quality
of the working alliance and gender in CM Counseling.



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Ho3b: There is no significant relationship between in the outcome efficacy
and gender in CM Counseling.

Ho3c: There is no significant relationship between the client reported quality of
the working alliance and gender in F2F counseling.

Ho3d: There is no significant relationship between the outcome efficacy and
gender in F2F Counseling.

Ho4a: There is no significant relationship between the client reported quality
of the working alliance and ethnicity in CM Counseling.

Ho4b: There is no significant relationship between the client reported
outcome satisfaction and ethnicity in CM Counseling.

Ho4c: There is no significant relationship between the client reported quality of
the working alliance and ethnicity in F2F counseling.

Ho4d: There is no significant relationship between the outcome efficacy and
race/ethnicity in F2F Counseling.

Ho5a: There is no significant relationship between the client reported quality
of the working alliance and visualizing learning style in CM Counseling. Ho5b: There is no significant relationship between the client reported
outcome satisfaction and visualizing learning style CM Counseling.

Ho5c: There is no significant relationship between the client reported quality of
the working alliance and verbalizing learning style in F2F counseling. Ho5d: There is no significant relationship between the outcome efficacy and
verbalizing learning style in F2F Counseling.

Ho6a: There is no significant relationship between the client reported quality of
the working alliance and introversion in CM Counseling.

Ho6b: There is no significant relationship between the client reported outcome
satisfaction and introversion in CM Counseling.

Ho6c: There is no significant relationship between the client reported quality of
the working alliance and extraversion in F2F counseling.

Ho6d: There is no significant relationship between the outcome efficacy and
extraversion in F2F Counseling.





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DgWri options of Vjfiables

The research design consists of random assignment of participants to one of two conditions. The conditions are face-to-face personal growth sessions and computermediated chat room personal growth sessions. Because the participants were randomly assigned to one of the two conditions, post-test only were used to measure the variables.

RO 3 face-to-face personal growth sessions Posttests

Ri 3 computer-mediated personal growth sessions Posttests

The three sessions were conducted to facilitators who will work with an equal number of participants in each condition, that is, if a facilitator works with a total of 10 participants, he or she will conduct three sessions face-to-face with 5 participants, individually, and 5 sets of sessions via computer chat room. Ten graduate students representing a broad population of counselors (I male, 9 females; I African American, I Hispanic; 3 licensed mental health counselors, 3 certified rehabilitation counselors; age range 23 to 56), from counselor education and rehabilitation counseling were hired and trained to conduct the personal growth sessions. The participants received extra credits in their counselor education interpersonal skills, substance abuse, or stress management classes, at the discretion of their instructor. The quality of the working alliance and the outcome satisfaction were measured to evaluate and compare the counseling experience in the two conditions. The individual differences that participants bring to the experience were measured to determine if any and which differences might predict better success with one condition or the other. For example, do introverted participants do better in one condition than they do in the other? Do Affican American participants benefit more from one condition than they do in the other? Is there any difference in the working alliance developed by participants with a verbal learning style in one condition versus the other?





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This could be a valuable contribution to pre-screening criteria for clients who apply for computer-mediated counseling.

Dependent Variables

There are two sets of dependent variables in this study, the participant perceived quality of the working alliance during counseling and the participant's report of outcome satisfaction with the personal growth counseling received plus the facilitators opinions on the same concepts. The working alliance is a process construct thought to describe the counselor-client relationship as it pertains to providing a helping environment for therapy to occur. It was measured with the Working Alliance Inventory. The clients' outcome satisfaction is a product construct that taps the results or benefits gained in therapy. It was measured with Outcome Satisfaction Questionnaire developed for this study and described above.

Indoendent Variables

The independent variables race/ethnicity, gender, learning style and

introversion/extroversion were investigated in this study. Ethnicity is an important variable because while the Internet makes democracy -- the free exchange of information and universal individual input more available to many, there is realistic concern that some are marginalized because of limited access to technological resources and strategically administered corporate or organization control of resources (Mantovani, 200 1, p. 5 1).

Gender has been suggested as a differential variable in cyberspace. Men have long dominated math, science and engineering careers. Internet access and savvy have grown out of training, familiarity and experience with computer technology. Therefore, there is concern that women have not had the exposure to computer technology to make





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this form of communication and counseling available to them. There is also concern that as women are thought to be more relational in their orientation while men are more analytical, computer-mediated counseling may disadvantage female clients.

Learning styles that favor visual learning, written expressiveness and/or

individual work may be more adaptive to Internet counseling while verbal learning, oral expressiveness and/or group work may be disadvantaged in a computer-mediated environment.

Personality type, likewise, may predispose some clients to more comfort and effectiveness using computer-mediated counseling and disadvantage others. The personality trait introversion/extroversion was an independent variable to determine if introversion is predictive of great outcome satisfactions than extroversion.

Population

The population was a southern university undergraduate population and from a community college in the same locale, with an age median of 20. This population is thought to be representative of computer users who use computers for social as well as technical purposes, have grown up in a technological age, and are of the age and social class most representative of computer users. Undergraduates volunteered for the study after hearing a presentation in their classroom, completing a contact sheet with demographic information, and signing an informed consent. They were provided with a duplicate of the informed consent form and were randomly assigned to personal growth sessions in either a face-to-face or computer-mediated counseling condition. Participants were enrolled in stress management, substance abuse, or interpersonal skill classes in the department of counsel education or in the student development classes at the community college. Students (N = 123; M = 29; F = 94) were contacted by their facilitator and





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scheduled for sessions. Upon the completion -of three personal growth sessions, the participant completed the MBTI, the CITE, the WAI (c) and the OSQ (p) in an encrypted website monitored by a survey technician available in chat room 5 of the site who was trained to answer any questions about the mechanics of completing the instruments that arose. The facilitator, who was not the monitor, completed the WAI (t) and the OSQ (f).

Sampling Procedure

Volunteers were recruited from the population of students enrolled in undergraduate counseling education classes in interpersonal skills and stress management. Most participants received a small amount (no more than 211/o of grade) of class credit for participation and three sessions of personal growth guidance. Participants were quasi-randomly assigned to the twelve facilitators and were randomly assigned to face-to-face or computer-mediated study conditions. Exceptions were made to random assignment to facilitators if the facilitator knew the participant or if the facilitator and participant were unable to find a mutually convenient time to meet. The facilitator each conducted an equal number of face-to-face and computer-mediated sessions. Preinduction paperwork included an informed consent, assurance that volunteers are at least 18 years of age, and provision of a code for confidential contact, a phone number, and/or an email address. All volunteers had adequate computer ability so that they could be randomly assigned to conditions. The university requires these skills of undergraduates and requires all undergraduates to own or have access to a computer with sufficient application software to participate in this study. The computer-mediated sessions were conducted in the university electronic learning gateway system WebCT. Many classes are offered or supplemented through this system so all students can be expected to learn how to use it at some point in their undergraduate career. The university has a computer





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help desk for students who have any difficulty accessing or using the system and participants were notified of these services.

Midway through the study, the University moved WebCT to an authenticated server that required identification at log on. However, the university maintained the original server for studies such as this that require anonymous or coded logon. This did not negatively affect the study in any way because site appearance remained the same to the facilitators and because the participants had never seen the other system. When participants navigated to the WebCT home page, they found this among other studies listed individually with a link to the older server (e.g. Participants in the Groble dissertation study click here nfbund was that the new server
J. The one possible co

relieved the lag time problem encountered in the spring term when the old server was overloaded. Facilitators either did not notice or did not mention any difference. The lag was inconsistent in the spring depending on the time of day of appointments.. The lag occurred when the system was experiencing heavy use throughout the university. The facilitators may have adjusted their scheduling to minimize this problem.

Data Collection Procedures

The principal researcher established a dedicated, password secured web site with a text-talk (chat room) application for use by facilitators who conducted the personal growth sessions and data collection. Recruitment was conducted in the source classrooms during regularly scheduled class with the instructor's permission to discuss the study, explain the participants' rights to withdraw without harm, obtained informed consent and contact information. The principal researcher did not access to the web site once the study begins and each assistant was instructed how to secure his or her





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participants' sessions. Sessions were downloaded with the permission of the participant for further research analysis outside the scope of this study.

Nine graduate students and one recent graduate from the Department of

Counselor Education or the Department of Rehabilitation Counseling were trained in the study protocol, study logistics, cognitive behavior therapy principles, WebCT use, Internet Resources for clients, and research on the typical personal growth issues of undergraduates. All training were conducted in person by the principal investigator who prepared the extensive, detailed manual each facilitator received. Additional computer specific training was provided by the principal investigator and by University personnel familiar with the WebCT resources. The principal investigator coordinated with the instructors for the interpersonal communications, substance abuse, student development, and stress management classes to present the study during class early in the term and recruit participants. Participants were contacted individually, randomly assigning to one of the two conditions, scheduled for first session, given any direction needed for finding the counseling lab or WEBCT chat room. The principal investigator was available via beeper during any sessions to insure the safety of participant and availability to the graduate student facilitators. Facilitators received weekly supervision in accordance with their program requirements (practicum, research, registered intern, and such) and project design.

The participants presented genuine concerns common to college undergraduates such as but not limited to adjustment to college life, time management, study habits, career indecision, roommate relations, and so forth. The facilitator contacted each participant to set up the first meeting. He or she gave directions for participation. When





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the participant was assigned to the face-to-face condition, the facilitator ensured that the participant understood where and when to meet with the facilitator. When the participant was assigned to the computer-mediated condition, the facilitator provided direction for the participant to log on to the chat room at the appropriate time and ensured that the participant understood how to log on to the system and navigate to the chat session space. The logistic of the experiment, detailed session outlines, record keeping forms, and the required readings list are located in the facilitators training manual in Appendix B.

Instrumentation

Working Alliance Inventor (Client)

The Working Alliance Inventory Client (WAI c) is a 36 item developed by Horvath (1984b, 1986) to be used early in the relationships between the P~ and 5th session. It was administered at the end of the 3P( session for purposes of this research. The Working Alliance Inventory targets the client-therapist relationship in a pantheoretical approach. (Horvath et al 1993 p. 255). It was designed to be counseling theory neutral while operationalizing Bordin's description of the three factor working alliance tasks, goals, and bond (Horvath & Greenberg, 1986). The WAI consists of 36 items, 12 relating to each of the factors of the working alliance. The WAI, client version has a Hoyt's estimate of reliability of .88 for the goal and task subscales, a Hoyt's estimate of reliability of .85 for the bond subscale and a Cronbach's alpha of .93 for the composite (Horvath & Greenberg, 1986). Items are rated on a Likert-like scale from one being never to seven being always.

Sample items (Horvath, 1984b)
"I find what I am doing in therapy confusing" (Tasks) "I am worried about he outcome of these sessions" (Goals) "(name of counselor) and I understand each other." (Bond)





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The advantage of these measure are that they have forms for both the participant and the therapist providing the opportunity to view the therapeutic relationship through both lenses. The forms are attractive, well researched and easy to understand and complete with a minimum of time and effort on the part of the participant. The questions are non-threatening and non-intrusive while tapping all three aspects of the working relationship defined by Bordin and fundamental to all therapeutic relationship instruments examined.

Working Alliance InventoKy (Therapist)

The Working Alliance Inventory Form T is the therapist version that assesses the therapist view of the working alliance across all three components of bond, task agreement and goal agreement.

Sample items (Horvath, 1984a)
"I feel uncomfortable with (bond)
My client and I both feel confident about the usefulness of our current
activity in therapy. (tasks)
and I have a common perception of her/his goals. (goals) Outcome Satisfaction C questionnaire

An outcome satisfaction questionnaire was developed for this study because outcome measure reviewed in the literature emphasized medical diagnosis and symptomatology or were site specific dealing with the mechanics of scheduling appointments and locating offices. Items for this outcome measure were written by the principle investigator or adapted from existing instrument where applicable. A committee of experts reviewed the potential items. A pilot study of the instrument was conducted at a local community college to gather feedback from students receiving counseling and from counselors regarding item wording, appropriateness, and face value. Information from the committee and from the community college study were





81


implemented into the final 12 item form developed for participants and 7 item form developed for facilitators. The facilitator form did not include qualitative questions found on the participant form.

Students rated their perception of their computer skills and their likelihood of seeking Internet counseling should they seek counseling in the future. They answered open-ended questions about what they least liked about computer-mediated communication as they had experienced it in this study and were encouraged to offer suggestions, comments, and ideas about the Internet interaction study. Facilitators were trained in adequate computer skills, as needed, before beginning their work on this project and were individually debriefed about the other points in end of study interviews. Myers Briggs T3= Indicator Form M OMTD

The MBTI is arguably the most researched and most widely used personality

instrument. The Singer-Loomis Type Deployment Instrument (Singer 1996) and Keirsey Type Indicator (1984/1996) are similar Jungian theory based instruments but less researched and less often applied. The Keirsey Type Indicator is readily available on the Internet, although no longer free. The Singer-Loomis is still considered to be a research tool, and as such not used in applied setting such as business, counseling, and career development. The strength of the Singer-Loomis is that it is built upon a dynamic theory of personality growth and change rather than what has been seen as the rather static typing of the MBTI The MBTI, however, was used in this study because the introversion/extroversion scale has consistently been found to have predictive and discriminative value. The Keirsey and Singer Loomis blend the four scales while the MBTI is more consistent with Jung's theory that introversion/extroversion is a attitude, while thinking/feeling and intuition/ sensing are traits. It is the introversion/extroversion





82

scale of the MBTI that was used in this study. Eysenck developed an introversion/extroversion scale as part of his three factors biologically based formulation of personality; however, it is more applicable to a clinical population than the population of this study.

The MBTI is statistically sound. The phi coefficient for reliability ranges from

.55 to .65 for the introversion/extroversion dimensions; .64 to .53 for the sensing/intuiting dimension; .43 to .75 for the thinking/feeling dimension and .58 to .84 for the judging/perceiving dimension. The tetrachoric coefficients are higher, .70 to .81 for I/E; .82 to. 92 for S/N; .66 to .90 for T/F and .76 to .84 for /P. Reliability is found to increase with the population's age and intelligence. When the data were converted to continuous scores the reliability estimates are more consistent at .76 to .82 I/E; .75 to .87 S/N; /69 to .86 T/F and .80 to .84 J/P. (Willis, 1984). Table 11.1 (Myers & McCaulley 1993, pp. 177-206) describes the validity studies correlations between the MBTI and the Adjective Check List by scales, the California Psychological Inventory by scales, the Comrey Personality Scales, by scales, the Edwards Personality Preference Survey by scales, the Emotions Profile Index by scales, the Eysenck Personality Questionnaires by scales, the Maudsley Personality Inventory by scales, the Jungian Type Survey by scales, the Minnesota Multiphasic Personality Inventory by validity and clinical scales, the Omnibus Personality Inventory by scales, the Personality Research Inventory by scales, the Stein Self Description Questionnaire by scales, the Brown Self Report inventory by scales, the Sixteen Personality Factor Questionnaire by scales and by second order traits, the State-Trait Anxiety Inventory by state and trait, the Study of Values by scales, The Rokeasch Dogmatism Scales, the Opinion, Attitude and Interest Scale by scales, the





83


Kuder Occupational interest Survey by college major and occupational scales, the Strong-Campbell Interest Inventory (now known as the Strong Interest Inventory) by occupational themes, the Kolb Learning Style Inventory by scales, the Science Research Temperaments Scale, the Watson Glaser Critical Thinking Appraisal, and lesser known instruments including the Conflict Management, the Harbaugh (W)holistic Scales, the Internal-External Locus of Control and the intolerance of Ambiguity. The body of work establishes the MBTI construct validity, divergent and convergent validity. Center for Innovating Teaching Expribences Learning Styles Inventory (CITE)

The Center for Innovative Teaching Experience, Murdock Teacher Center,

Wichita Kansas School District developed the Learning Style Inventory most prevalently used in education today. The CITE Learning Style Instrument is composed of 45 items that the respondent scores 4, 3, 2, or 1. A score of 4 on an item means that the respondent feels the statement is "most like me" while a score of 1 indicates that the statement is "least like me". Results were calculated for nine subscales, visual language, visual numerical, auditory language, auditory numerical, kinesthetic-tactile, social-individual, social-group, expressiveness-oral and expressiveness-written (Babich et al., 1976). For the purposes of this study, the visual numerical and auditory numerical are thought to be irrelevant to the counseling context but were analyzed in case they tap symbolic language. Items were scored for each category and significance or "major learning style" is determined by a cut score of 33 on any scale. The split-half reliabilities were .6 or better for eighty-five percent of the constructs.

Sample items (Babich et al., 1976)
"I remember things I hear better than I read" (Auditory) "I would rather read a story than listen to it read." (Visual)





84

Richardson developed a visualize verbalizer scale; however, it has not been used outside research and is thought to be less applicable to this study than the visual and auditory scales of the CITE that has been widely used with adult populations and formed to the same population as this study. Richardson's scale was formed to a middle school population and the forming sample was small. DemogLaphics

Participants were asked to indicate their age, gender, and race or races. It seems unlikely that the population of convenience have have any significant variance in age or gender but these questions were asked in case the perception of homogeneousness is erroneous. The age question was not relevant, however the gender question returned essential data. The ethnic composition of the population of this study was expected to be diverse and thought have significance in the working alliance and outcome of the face-toface or computer-mediated sessions.

Data Analyses Procedures

Data were analyzed using SPSS 11.0. ANOVA procedures were used to analyze the data because this procedure is sensitive to relationships between the independent variables, gender, ethnicity, learning style and personality traits and the dependent measures. Means and standard deviation were computed for all significant main effects and interactions to evaluate the efficacy of computer-mediated counseling compared to face-to-face counseling in the process dimension, working alliance and the outcome dimension efficacy.












CHAPTER 4
DATA ANALYSIS

The purpose of this study was to evaluate the efficacy of brief, cognitive

behavioral therapy provided on the Internet in real time chat room modality. The study compared two sets of participants. Participants in one set met with the protocol trained graduate counseling student facilitators face-to-face. Participants in the other set met with protocol-trained graduate counseling student facilitators via the Internet in a University of Florida, WebCT, classroom chat room. All participants and all facilitators completed the dependent variable' surveys via the Internet through the WebCT evaluation utility that provided anonymity for surveys. The chat room was set up so that participants entered by code rather than by name.

Descriptive Statistics for ftendent Measures

This study used four instruments as dependent variables. Two forms of The

Working Alliance Inventory were used, form c for clients and form t for therapist. The Working Alliance Inventory provided a total score as well as three sub scores per version. The student version of the Outcome Satisfaction Questionnaire measure provided three scores and qualitative responses for future analysis. Common to both the participant form and facilitator form was the outcome satisfaction scale. In addition, participants estimated their computer use skill on a Likert-like scale and predicted the likelihood that they would choose computer-mediated counseling in the future. High scores indicate positive responses for the WAI while low scores report favorably on the OSQ. That is, the closer a participant's score is to the minimum for outcome satisfaction, predicted 85





86


future use, and computer skill the greater their positive response. The closer a person's score is on any of the WAI versions or scales is to the maximum, the more positive the response.

The data was evaluated using analyses of variance (ANO VA), that require that the independent variable or factor consist of two or more levels and that those levels cover all possible levels of interest to the researcher (e.g., male, female). The levels were qualitative (e.g., face-to-fatce, computer-mediated personal growth sessions) or quantitative (e.g., MBTI introversion/extraversion). The participant endorsed one and only one level of each factor. Each independent variable in this study met the criteria. The critical F value to disprove the Null hypothesis at the .05 confidence level is F (Tiw~ 1, 123) = 3.92. The independent factors or variables were condition to which the participant was randomly assigned, ethnicity, gender, academic learning style, personality attitude, temperament learning style.

Table 1 depicts the meaningful descriptive statistics for the independent variables

- gender, ethnicity, academic learning style, trait learning style, and attitude and for the dependent variables working alliance, by scales, outcome satisfaction, predicted future use, and computer/Internet skill level. The table is organized by experimental conditions, face-to-face and computer-mediated treatments. Table 2 presents the factors and levels of each factor used in the analyses of variance.

Participant Depedent Variables Analysis

To evaluate outcome efficacy, participants were asked to evaluate the quality of their experience in the face-to-face or computer-mediated conditions and their outcome satisfaction. They were asked to predict if they thought they would be likely to use computer-mediated counseling in the future. They were asked to describe their comfort





87


and skill level with using a computer and using the Internet. To allow the researcher to

examine the process efficacy of these sessions in the two conditions, participants

answered questions about their total evaluation of the working alliance they co-created

with their facilitator.

Table I Descriptive Statistics for Dependent Variables by Conditions

Variables N Minimum Ma~amum Mean Std.
Deviation
FACE-TO-FACE CONDITON
WA! Task (client) 59 7 44 32.88 8.748
WA! Bond (client) 59 14 60 48.00 10.609
WA! Goal (client) 59 2 38 25.05 8.330
WA! Total (client) 59 23 140 103.93 24.676
Satisfaction (participant) 59 7 27 12.64 4.877
Computer Skill participant) 59 2 7 4.00 1.218
Predicted future use (participant) 59 0 3 .95 .705
WA! Task (therapist) 58 -4 42 27.74 9.049
WA! Bond (therapist) 58 30 80 49.31 8.217
WA! Goal (therapist) 58 -14 33 18.74 10.597
WA! Total (therapist) 58 17 127 95.79 25.380
Satisfaction (therapist) 58 8 23 15.83 3.738
COMPUTER-MIEDIATED CONDITON
WA! Task (client) 64 11 44 31.27 8.016
WA! Bond (client) 63 23 60 45.67 8.160
WA! Goal (client) 83 3 36 24.13 7.722
WA! Total (client) 63 52 137 101.22 21.372
Satisfaction (participant) 63 7 24 13.76 4.294
Computer Skill participant) 63 2 10 4.27 1.096
Predicted future use (participant) 63 0 2 .70 .887
WA! Task (therapist) 63 2 44 28.85 9.172
WA! Bond (therapist) 63 34 60 48.86 7.118
WA! Goal (therapist) 63 -8 38 19.57 10.171
WA! Total (therapist) 63 29 137 96.64 24.022
Satisfaction (therapist) 64 7 25 16.42 4.227


The inventory subscales indicated the strength of the personal relationship (bond),

the mutual creations of tasks, which would lead to accomplishing the goal set for these





88

sessions, and ability to delimit, define and specify a goal. The results of their responses are discussed in the text below and displayed in tables three through twenty-four below.


Table 2: Independent Variables, Levels of Each Variable and Number of Participants at Each Level

Factors Levels Number of
participants
Conditions Face-to-face 58
Computer-mediated 64
Gender Male 29
Female 94
Ethnicity Caucasian 94
African American 12
ffispanic 17
Academic Learning Styles Visual learners 30
Verbal learners 93
Introversion/ Extraversion Extraverts 88
Introverts 35
Temperament Learning Styles Intuitive Thinking (NT) 18
Intuitive Feeling (NF) 53
Sensing Judging (SJ) 41
Sensing Perceiving (SP) I I


Predicted Riture use participantt

Participants were asked to predict the likelihood that they would choose

computer-mediated counseling should they decide to seek out counseling of their own volition rather than being randomly assigned to a condition as in the present study. Table 3 shows the results of the ANOVA. The main effect, learning style, was significant (F = 4.25, p = .042) but no interactions between face-to-face or computer-mediated counseling and the independent variables were significant.





89


To further analyze the relationship between academic learning style preference

and predicted use, follow up tests were applied. For this variable, the lower value

indicates preference and the higher the score indicates negative responses.

Table 3 Source Table Dependent Variable -participant predicted future use of computer-mediated counseling

Sources of Variance Type III Sum df Mean F Sig.
of Squares Square
Corrected Model 7.673 17 .451 .897.580
Intercept 15.869 1 15.869 31.520.000
Condition .280 1 .280 .556.457
Gender .319 1 .319 .633.428
Ethnicity 6.576E-02 2 3.288E-02 .065.937
NWOOWWO im 1 WN mog
Introversion/Extraversion 8.22i '1*8.222E-04 .002'."
Temperament Learning Style 1.139 3 .380 .754.522
Condition by Gender 2,739E-02 I 2.739E-02 .054.816
Condition by Ethnicity .319 2 .159 .317.729
Condition by Academic Learning Style .113 1 .113 .224.637
Condition by Introversion/ Extraversion .606 1 .606 1.204.275
Condition by Temperament Learning Style .309 3 .103 .205.893
Error 52.360 104 .503
Total 142.000 122
Corrected Total 60.033 121

Table 4 displays the resulting means and standard deviation. Those who use a visual

learning style predicted that they would be more likely to seek computer-mediated

counseling should they need counseling in the future (M =.56 SD =.58), consistent with

the study hypothesis that visualizers would be more likely to seek computer-mediated

counseling than verbal or auditory learners (M = .89, SD = .72).

Table 4. Means and Standard Deviation for Significant Main Effect Academic Learning Styles; Dependent Variable Predicted Future Computer-Mediated Counseling Use

Academic Learning Style Preference Mean Std. Deviation
Visual learners .56 .583
Verbal learners .89 .720




Full Text
116
compromised. The study results will be published as a dissertation and available in the
University of Florida George A. Smathers Library after it has been completed.
Voluntary participation:
Your participation in this study is completely voluntary. There is no penalty for not
participating. There is no penalty for deciding to withdraw from the study at any time.
Right to withdraw from the study:
You have the right to withdraw from the study at any time without consequence.
Whom to contact if you have questions about the study
Martha L. Groble, graduate student, Department of Counselor Education
Martve@att.net
(904) 387-2617
James Archer Jr, PhD, College of Education, Department of Counselor Education
Jarcher@coe.ufl.edu
(352) 392-0732 extension 231
Whom to contact about your rights as a research participant in this study:
UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250
(352) 392-0433
Agreement:
I have read the procedure described above. I voluntarily agree to participate in the
procedure and I have received a copy of this description.
Participant: Date:
Principal Investigator: Date:


141
PARTICIPANTI would change his outer appearance and give him another
chance. I have changed over the year and my prefences are very much
different now. Appearance wise.
FACILITATORhow would you see things right now but in your perfect
world?
FACILITATORok, ignore my last comment!
FACILITATORbut, what about his inner, are you still in love with
that?
PARTICIPANTFred would be taller, slimmer, no drama attached. I love
him, but not in love.
FACILITATORgot it
FACILITATORok, so let me tell you . .we are going to try something
called REBT. Basically, it is a way of analyzing you actions
PARTICIPANTok
%
FACILITATORI 'm going to try to explain a little bit about it, and
then give you as "homework" something to use it on
PARTICIPANTok
FACILITATORBasically, when we have an event and then a reaction, we
often have a thought in the middle of it that influences our reaction.
But, often, we arent aware of the thoughts
FACILITATORso, we react "without thinking".
FACILITATORfor example, I come home from school, the dishes are
still in the sink, and my husband is there and has been home all day
PARTI Cl PANTyou yell
FACILITATORI get mad, because the dishes aren't clean
FACILITATOR right
FACILITATORbut the underlying thought there that made me angry was
that he was lazy, and could have or should have cleaned up the dishes
PARTICIPANTok
FACILITATORnow, that thought can or cannot be correct, but if I
change my thought process, I might not get mad
PARTICIPANTok
FACILITATORfor example, if instead I think, "well, he must have been
doing something very stressful in order not to be able to clean up the
dishes", then how might I react?
PARTICIPANTcalm


155
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74
This could be a valuable contribution to pre-screening criteria for clients who apply for
computer-mediated counseling.
Dependent Variables
There are two sets of dependent variables in this study, the participant perceived
quality of the working alliance during counseling and the participants report of outcome
satisfaction with the personal growth counseling received plus the facilitators opinions on
the same concepts. The working alliance is a process construct thought to describe the
counselor-client relationship as it pertains to providing a helping environment for therapy
to occur. It was measured with the Working Alliance Inventory. The clients outcome
satisfaction is a product construct that taps the results or benefits gained in therapy. It
was measured with Outcome Satisfaction Questionnaire developed for this study and
described above.
Independent Variables
The independent variables race/ethnicity, gender, learning style and
introversion/extroversion were investigated in this study. Ethnicity is an important
variable because while the Internet makes democracy the free exchange of information
and universal individual input more available to many, there is realistic concern that
some are marginalized because of limited access to technological resources and
strategically administered corporate or organization control of resources (Mantovani,
2001, p. 51).
Gender has been suggested as a differential variable in cyberspace. Men have
long dominated math, science and engineering careers. Internet access and savvy have
grown out of training, familiarity and experience with computer technology. Therefore,
there is concern that women have not had the exposure to computer technology to make


142
FACILITATORyou got it.
FACILITATORso, what we can do is this. Maybe we might need to sort
through your thoughts and feelings a little more next session, but you
said that at least right now you just want to work through your feelings
and get over them
FACILITATORright?
PARTICIPANTyes
FACILITATORso, what I was explaining is with REBT what we try to do
is figure out our underlying thoughts that might be getting in the way
PARTICIPANTok
FACILITATORso, how do you think we might apply that to your
situation with Fred and/or the other guys?
FACILITATORgot any ideas?
PARTICIPANTfear of commitment has an underlying thought of "I will
be deceived"?
FACILITATORgood. But even more so, "I will be deceived every time?"
really good
PARTICIPANT! see
FAClLlTATORok (misprint, I meant no questionmark) smile
PARTICIPANT:-)
FACILITATORso, since this is coming to a close, what do you think we
could have you do for this week until next session?
PARTICIPANT! don't know
PARTI Cl PANTtalk to the guy that I could see myself with? Confront
old boyfriend?
FACILITATORThose could be ideas, but probably right now you need to
confront yourself more than others. cause for example you said that you
might like the guy if YOU could get over this. but that might come at a
later stage
PARTICIPANTok
FACILITATORhow about you make a list of three things that Fred did,
and how you reacted. And then try to apply what we were talking about,
about the underlying thoughts, and how you carry them over.
FACILITATOR
FACILITATORDoes that make any sense at all?


88
sessions, and ability to delimit, define and specify a goal. The results of their responses
are discussed in the text below and displayed in tables three through twenty-four below.
Table 2 Independent Variables, Levels of Each Variable and Number of Participants at
Each Level
Factors
Levels
Number of
participants
Conditions
Face-to-face
58
Computer-mediated
64
Gender
Male
29
Female
94
Ethnicity
Caucasian
94
African American
12
Hispanic
17
Academic Learning Styles
Visual learners
30
Verbal learners
93
Introversion/ Extraversin
Extraverts
88
Introverts
35
Temperament Learning Styles
Intuitive Thinking (NT)
18
Intuitive Feeling (NF)
53
Sensing Judging (SJ)
41
Sensing Perceiving (SP)
11
Predicted future use (participant!
Participants were asked to predict the likelihood that they would choose
computer-mediated counseling should they decide to seek out counseling of their own
volition rather than being randomly assigned to a condition as in the present study. Table
3 shows the results of the ANOVA. The main effect, learning style, was significant (F =
4.25, p = .042) but no interactions between face-to-face or computer-mediated counseling
and the independent variables were significant.


24
were those who passionately and persistently accused
the eulogizers of exhibiting a hypocrisy that stank unto
the heavens, because of our not altogether charitable
treatment of Blair Internet when he was alive.
Those of us who had made the calls to Blair and his
shrinks, who went out and met his brother and his
mother and tried to provide them some comfort, had a
different attitude toward those who couldnt bring
themselves to attend the painful event in person but
didnt hesitate to heckle others Internet. People who
had to live with each other, because they were all
veteran addicts of the same social space, found
themselves disliking one another (p. 37).
And...
There has always been a lot of conflict in the
WELL, breaking out into regular flamefest of
interpersonal attacks from time to time. Factionalism,
Gossip. Envy. Jealousy. Feuds. Brawls. Hard feelings
that carry over from one discussion to another (p. 53).
Thought, feelings, and behaviors are the raw materials of counseling.
Rheingolds experiences provide poignant insights into the thoughts, feelings and
behaviors Internet and in the real life of a multinational, Internet, social community.
From social psychology, the construct of disembodied engagement and personal
interaction over the Internet has been named presence. Lombard and Ditton (1997)
identify presence as the sense that mediated experience (computer, simulation rides,
home theater, video conferencing) is natural, immediate, direct, real and unmediated.
This qualitative factor of mediated communication is crucial to community building and
counseling. An enhanced sense of presence is central to the use, and therefore the
usefulness and profitability, of the new technologies... These technologies either are now
changing or are expected soon to change many of the ways we work, play and live (p.
2). Social presence theory was studied early in the advent of mass, affordable access to
electronic media and continue to be important in social psychology and mass
communication research.


38
Barak et al (1999) conducted one of the only empirical studies reported. He and
his team chose synchronic chat groups for their research because e-mail, the most
common form of Internet therapy,
lacks a key feature of human interpersonal
communication characterized by spontaneity, authenticity,
immediacy and directness. This feature is directly related
to the commonly accepted and generally appreciated
therapeutic factor of here and now. Numerous schools of
psychotherapy argued that this immediacy factor may be
responsible to a great degree for dramatic therapeutic
developments. In addition, defense mechanisms or
cognitive distortions (depending on the school of therapy)
are less, likely to take place in a here and now therapeutic
situation, (p. 1)
In this study of brief Internet Chat room group therapy, Barak, recruited 15
students from several Israeli universities and community colleges. Six participants (three
men, three women) were assigned to the Internet condition and nine students (three men
and six women) were assigned to a traditional face-to-face group therapy. Both groups
were led by experienced, female therapists and were brief, dynamically oriented. One
therapist conducted the Internet group while the other conducted the face-to-face group
therapy. The Internet condition was conducted in a JavaScript, password protected chat
room for seven, ninety-minute sessions. The face-to-face group met on the campus of the
University of Haifa. The dependent measures were Measure of Therapy Impact: Self-
Esteem, Social Relationship, and Well-being. Each scale was a 25 item Likert-like scale
but Barak does not cite the source of these measures Moose (1981) developed the group
process measure, a Likert-like evaluation questionnaire designed to elicit opinions about
the Internet group therapy experience. Because of the small number of participants in


2
Although the technology and evolution of virtual reality are 30 years old, its
application in counseling has not yet been significantly engaged. The virtual counseling
world is the quintessential postmodern constructionist therapy environment. Fink (1999,
pp. 28-29) reasoned, computer-mediated communication (CMC), clearly a postmodern
phenomenon, are a form identified by the mediator (the computer) as well as by the
communicator (the virtual ego). The machine determines existence. . (u)sing present
technology, CMC tends to be fluid, cycling, and devoid of social cues, which constitute
modernity. Accordingly, psychotherapy that uses CMC is also amorphous, shifting in
response to context, technology and the nature of patient interaction. In essence, the
counselor and client co-create the cyber counseling experience in the material processed -
behavioral issues, distorted thoughts, troubling problems, faulty cognitions,
overwhelming emotions and in the very essence each participant chooses to contribute
to the structure of the working space. Language, spoken or written, forms the connection
between two people. Stanley (2001) argued that rather than language being a reflection
or mirror of social life, language itself constructs social life when it is practiced.
Discourses produce different versions of this social life, different realities. The goal of
discourse analysis then is not to improve upon peoples accounts, but rather to understand
how they are practically achieved.
Much of the power differential between client and counselor dissipates when each
presents without the hallmarks of embodied age, race, gender, physical attractiveness,
size and shape, native language, dialect, speech impediments, or peculiar mannerisms,
which color and may distort face-to-face communication with preconceived stereotypes
and subtle biases. For example, the researcher had a revealing chat experience with an


19
provides assistance in disaster stricken areas throughout the world and applies space-
based technology to terrestrial medical care.
URL the address or location of information on the Internet. The acronym stands for
Universal Resource Locator (Young 1998), although Berner-Lee (2000), a particle
physicist who created the World Wide Web, originally used URI for Uniform Resource
Identification and the terms are often confused because the URI is still used for addresses
on the Internet outside the worldwide web. The URL of a popular search engine for
example is http://www.google.com. While most clients will see the URL, the direct form
is http://216.199,19,139/ the URI of a small business in Jacksonville. An email address is
not a URL or a URI but rather a hyperlink to a section (bin) within the service providers
website.
Virtual Reality (VR) immersion technology currently being used at MIT and
elsewhere to treat pain and phobias. VR is a graphic and animation rich computer
environment, which simulates visual, auditory and tactile sensations. For
microcomputers, (PCs and Macs) VR uses MOO (MUD Object Orientation) virtual
reality programming code that allows the creation, use, and manipulation of items on the
screen. MUD is Multi-User Dungeons, (now also Multi-User Domains, Multi-User
Dimensions) a virtual world originally developed in the 1970s and 1980s for playing
adventure role-playing games. MUSH is Multi-User Shell, a programming system that
allows users to develop and manage either an adventure or a social MUD (Bruckman
1995). This technology can potentially be used to develop VR counseling from any
computer given adequate bandwidth and baud rate to both the counselor and client
computers.


150
Grohol, J. M. (2001a). Best practices in e-therapy: Definition and scope of e-
therapy. [web document], PsychCentral. Retrieved 07/18 2001, from the World Wide
Web: http://psychcentral.com/best/best3 html.
Grohol, J. M. (2001b). Best practices in e-therapy: Legal and licensing issues*
[web document]. PsychCentral. Retrieved 07/18 2001, from the World Wide Web:
http: //psychcentral. com/best/best4. html.
Grohol, J. M. (2001c). Best practices in e-therapy: Clarifying the definition [web
document]. PsychCentral. Retrieved 07/18 2001, from the World Wide Web:
http ://psychcentral. com/best/best2. html.
Gurainik, D. B. (Ed ). (1979). Webster's new world dictionary (modem desk
edition). New York, NY: Simon and Schuster.
Haas, C. (2000). Online counseling presents challenges for mental health experts,
[web document]. Counseling Today Retrieved 06/20 2001, from the World Wide Web:
http ://www. counseling. org/members/ctonline/ct0200/etherapy. cfm.
Haas, C. (2000). Entangled in the Net: Online counseling can turn Youve Got
Mail into Youve Got Help. [web document]. Counseling Today. Retrieved 06/20
2001, from the World Wide Web:
http://www.counseling.org/members/ctonline/ct0100/intemet.cfim.
Harris, S. (2002) Emotional support on the Internet VI.35. [web document].
Retrieved 06/20 2001, from the World Wide Web: http://www.cix.co.uk/~net-
services/care/1 i st. htm.
Harris-Bowsbey, J. (2000). The Internet: Blessing or bane for the counseling
profession? In J. Brown & G. R. Walz (Eds.). Cybercounseling and cyberleaming:
Strategies and resources for the new millennium. (39-49). Alexander, VA: American
Counseling Association.
Hartley, D. E. & Strupp, H. H. (1983). The therapeutic alliance: Its relationship to
outcome in brief psychotherapy In J. Masling.(Ed). Empirical studies in analytic theories.
(1-37). Hillside, NJ: Erlbaum.
Health Care Financing Administration. (1996). Operational policy letter #41,
telemedicine service, [web document]. US Government. Retrieved 07/08 2001, from the
World Wide Web: http://www.hcfa.gov/medicare/opl04.htm.
Health Care Financing Administration. (1999). Medicare and telemedicine, [web
document], US Government. Retrieved 07/08 2001, from the World Wide Web:
http ://www. hcfa. gov/medicaid/telemed. htm.


13
thoughts, feelings, hopes, dreams and wishes. The therapists special contribution is to
guide the patient about what data to collect and how to utilize these data therapeutically
(p. 54). Other collaborative techniques include authenticating introspective data,
investigating underlying assumptions, setting up experiments, and homework
assignments all of which are conceptualized as making the client his or her own folk
scientist whose research is focused on his or her own best interest, personal problem
solving and successful living.
The process of therapy and the outcome satisfaction as reported by both the
participant and the facilitator were evaluated to determine the efficacy of computer-
mediated counseling. A therapy outcome is related to both what happens during the
therapeutic process and what the participants bring to the process. This study examined
cultural factors and personality traits that the client brings to the therapeutic process,
gender, ethnicity, learning style, and personality traits.
Learning style theory, an operational application of information processing
research, is an important construct that identifies inherent learning strength and examines
differential sensory and social ways in that people prefer to learn and learn most
successfully (Babich 1976). Personality traits or the hard wiring of individual differences
in attitude, response to the stimuli, collection of information from the world and source of
energy and authority were simultaneously suggested by Jung and by the mother daughter
team, Myers and Briggs. Myers and Briggs (Myers 1962) operationalized Jungs theory
in the Myers Briggs Type Indicator (MBTI). Of particular interest in this study is the
introversion/extroversion scale, because Reid (1994) and Fink (1999) each suggested that
computer-mediated communication favors those with an introverted attitude. Jungians


84
Richardson developed a visualize verbalizer scale; however, it has not been used
outside research and is thought to be less applicable to this study than the visual and
auditory scales of the CITE that has been widely used with adult populations and normed
to the same population as this study. Richardsons scale was normed to a middle school
population and the norming sample was small.
Demographics
Participants were asked to indicate their age, gender, and race or races. It seems
unlikely that the population of convenience have have any significant variance in age or
gender but these questions were asked in case the perception of homogeneousness is
erroneous. The age question was not relevant, however the gender question returned
essential data The ethnic composition of the population of this study was expected to be
diverse and thought have significance in the working alliance and outcome of the face-to-
face or computer-mediated sessions.
Data Analyses Procedures
Data were analyzed using SPSS 11.0. ANOVA procedures were used to analyze
the data because this procedure is sensitive to relationships between the independent
variables, gender, ethnicity, learning style and personality traits and the dependent
measures. Means and standard deviation were computed for all significant main effects
and interactions to evaluate the efficacy of computer-mediated counseling compared to
face-to-face counseling in the process dimension, working alliance and the outcome
dimension efficacy.


113
presenting problems already include in this article of the code. The NBCC (2001)
ethics for the practice of Internet counseling includes a section entitled Internet
Counseling Relationship which offered direction for dealing with suspected imposter
clients and minors. The board should consider adding a item in this section about
individual differences, known and yet to be identified.
Internet counseling exists. As the professional associations struggle with
developing working papers and preliminary ethical guidelines, the research community
can provide the data needed to advise these decisions. Clinicians must practice well and
ethically to set the tone and expectations for this new frontier in mental health service.
This study begins to explore the personal characteristics that can be used in
potential screening for appropriateness of Internet services for a given client or
population of clients, or in the absence of clear cut reasons to pre screen, can be used to
advise the therapist to insure that the differential potentials are considered. The core
issues remain to be investigated more thoroughly efficacy of Internet counseling,
format and restrictions to maximize efficacy, and individual differences of potential uses
that can enhance or limit outcome results and satisfaction.


123
I will work with each facilitator to insure that you are comfortable using WebCT,
working to the session room and helping your participants get there as well
(Martve@,att net). You can always get help from the university help desk 392-help for
login problems. Be sure you have these worked out for yourself and for your participant
before your first scheduled personal growth session. For big problems, Doug Johnson is
a very user-friendly administrator of WebCT and you can reach him through the CIRCA
help desk. Be sure to mention that project you are with when you leave him a voice
message.
We are only using rooms 1 through 4 for participants, however I would like to
schedule facilitator meetings with me in the general chat for dissertation room and you
may use the General Chat for all rooms to consult with one another (but not with
participants). The assessment tech will wait in room 5 during CMC administrations to
answer any question or help the participant.
STUDY MEASURES
The facilitator fills out two measures at the end of the third session. The participant will
fill out four measures at the end of that session. Administration will be conducted by
Loren so please give him your schedule of the last sessions so he can be present at the
proper time to conduct the assessments.
TAPES AND RECORDS
When you have completed the entire process with a participant return tapes, treatment
plans, contact sheets, progress notes, and so forth to me. Turn in tracking sheets by email
weekly so we can keep track.


Process efficacy was measured with the Working Alliance Inventory (WAI),
forms client and therapist. The WAI provides a score for total alliance, and sub-scores
for bond, task, and goal, key factors in the development of a therapeutic milieu. Outcome
efficacy was measured with a researcher developed Outcome Satisfaction Questionnaire
with three scales, outcome satisfaction, computer skill level, and prediction of likelihood
of future use of computer-mediated counseling.
The independent demographic variables, age, ethnicity and gender, were collected
from the contact information form completed during recruitment. Learning style
preference was determined using the C.I.T.E. Learning Styles Inventory and the Meyers
Briggs Type Indicator (MBTI). Personality attitude preference introversion or
extraversin was determined using the MBTI.
Significant main effects were found for the academic learning style systems and
for gender. Significant interactions were found for gender by condition indicating that
males reported greater process ability in the face-to-face condition contrary to a study
hypothesis. No significant results were found for age, ethnicity, introversion/
extraversin or research condition. Recommendations for further research and clinical
applications are discussed.
xi


91
This result is interesting and should be interpreted with caution because it is likely that
the instrument eliciting skills and comfort may need to be enhanced for greater accuracy
(see discussion, chapter 5). .
Table 6. Means and Standard Deviation -Dependent Variable, level of computer/
Internet skill and comfort (participant), Independent Variable, academic learning style.
Academic Learning Style
Mean
Std. Deviation
Visualizer
4.56
1.530
Verbalizer
4.03
1.025
Outcome Satisfaction (Participant)
Participants responses about their outcome satisfaction did not produce any
significant main effect or interaction in the outcome satisfaction measure (Table 7).
Table 7. Source table for dependent variable outcome satisfaction (participant)
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F
Sig.
Corrected Model
356.389
17
20.964
.989
.476
Intercept
5308.807
1
5308.807250.434
.000
Condition
16.177
1
16.177
.763
.384
Gender
25.548
1
25.548
1.205
.275
Ethnicity
84.967
2
42.484
2.004
.140
Academic Learning Style
7.598
1
7.598
.358
.551
Introversion/ Extraversin
9.763
1
9.763
.461
.499
Temperament Learning Style
59.018
3
19.673
.928
.430
Condition by Gender
31.766
1
31.766
1.499
.224
Condition by Ethnicity
29.799
2
14.899
.703
.498
Condition by Academic Learning Style
5.441E-02
1 5.441E-02
.003
.960
Condition by Introversion/ Extraversin
24.616
1
24.616
1.161
.284
Condition by Temperament Learning Style
24.496
3
8.165
.385
.764
Error
2204.636
104
21.198
Total
23887.000
122
Corrected Total
2561.025
121
a R Squared =167 (Adjusted R Squared = .021)
The most positive outcome satisfaction score possible was seven. The score indicating
the greatest possible dissatisfaction with the experience was twenty-eight. The observed


98
Working Alliance Inventory Bond (therapist)
Table 17 shows that the gender variable produced a significant main effect in the
facilitator scores for bond (F = 9.97,p = .002). Gender by condition was a significant
interaction in the WAI (t) task sub score (F = 7.33, p = .008). The significant interaction
between gender and condition in the facilitator version is on the sub scale bond.
The Mean and Standard Deviation for the gender main effect is not reported
because it is superceded by the significant gender by condition interaction presented in
Table 18. Facilitators recognized a stronger sense of rapport on bond with female
participants than they did with male participants. Since the participants, (Table 7), did
not indicate any significance in the strength of bond developed it may be that the female
participants were better able to communicate the sense of bond to their facilitator even
though male participants seem to have experienced a similar level of bond.
Table 16: Means and Standard Deviation for Main Effect Gender Dependent Variable:
Working Alliance Inventory (t) total
Gender
Mean
Std. Deviation
Male
83.83
34.118
Female
100.28
19.303
The interaction of gender by condition an important finding in this study that
seeks to identify potential sources of individual differences that may impact the value of
computer-mediated counseling and may be used as a screening factor. It would appear
that male participants were better able to develop and communicate that development of
rapport with their facilitator in the computer-mediated condition (M = 49.33, SD = 7.64)
than in the face-to-face condition (M = 42.86, SD = 8.51), while female participants were


25
Cyber feminist Plant (1996) warned that the Internet disembodies, degenderizes
and promotes yet another form of oppression. Stanley (2001) and others (McLuhan &
Friore 1967, Billig 1996, Shotter, 1993, Turkle, 1995) countered that language embodies
the authentic self and depoliticalizes the communication. Stanley disputed the concept of
virtual space saying, a social space (is) constructed through which embodiment could be
revealed. This reality is real space, the space that is on the other side of the screen ...
real space constitutes the embodied practice of social talk (p. 77). He suggested
interpersonal life is a dynamic performance of language constructed in speaking and
writing, not in thinking or holding unexpressed opinions and attitudes. Rather than
language being a reflection or mirror of social life, language itself constructs social life
when it is practiced. Discourses produce different versions of this social life, different
realities (p. 79). Stanley works with international students for whom life with family
and friends of necessity is text based. He analyzed the text-based interviews with distant
students/participants and identified recurring themes. Quotation marks are used to signal
stake and accountability. Subjectivity and reality, marked by the use of humm and
erm, Stanley noted is an archetype of phonetic space (that) has been appropriated for
use in cyberspace (p. 86). He found that the bodily presence of the person using the
Internet is present in the use of emoticons (emotion icons) and by typing speed, pauses,
and deletions. Language itself embodies in metaphorical phrases. Boechler (2001)
makes much the same argument from a cognitive process and concept point of view.
Much of the debate over presence and embodiment (Harris-Bowlsbey 2000, King
& Moreggi 1998, Laszlo, Esterman, & Zabko 1999, Miller 1995, Plant 1996, Powell
1998, Reid 1994, Suler 1999, Walther 1996) has or needs to examine how presence,


39
this study, the data were evaluated qualitatively by analyzing chat room transcripts in
addition to reviewing the results of the dependent measures.
Results indicated that participants exhibited positive support, personal disclosures,
interpersonal sensitively and group cohesiveness. No comparison with the face-to-face
group was reported. Recommendations for further research include a study of
preparation for therapist for Internet therapy, and rules by which such groups should
operate (Barak & Wander-Schwartz, 1999).
Multi-modal
Colon (1994), a prominent social worker, conducted one of the first studies of
Internet psychotherapy. She conducted a three-month study with eight participants using
email, chat and bulletin board. Participants were recruited and screening Internet from
ECHO subscribers. Participants were screened, refrained from in person contact with one
another or Colon, posted/participated actively at least three times a week and participated
for three months. Colons training was psychodynamic and so were her Internet groups.
Her primary concern about the experiment Internet groups was the absence of non-verbal
cues. (p. 9). She concluded In Internet therapy, and perhaps in the psychoanalytic
session, language is action. Nothing happens Internet, or for all intents and purposes,
in therapy. There is no way to quantify what happens in an Internet group. And yet lives
can change.
Phillips (1996) qualitatively compared four groups within which she participated,
an Internet service Adult Children Of Alcoholics (ACOA) chat group, an Internet service
ACOA email list, an Internet ACOA email list and an ACOA chat group she created on
the Internet service. None of these groups appear to be formal groups with regular
attendance, ground rules and on going interaction as defined by Yalom (1995) whom


79
the participant was assigned to the face-to-face condition, the facilitator ensured that the
participant understood where and when to meet with the facilitator. When the participant
was assigned to the computer-mediated condition, the facilitator provided direction for
the participant to log on to the chat room at the appropriate time and ensured that the
participant understood how to log on to the system and navigate to the chat session space.
The logistic of the experiment, detailed session outlines, record keeping forms, and the
required readings list are located in the facilitators training manual in Appendix B.
Instrumentation
Working Alliance Inventory (Client)
The Working Alliance Inventory Client (WAI c) is a 36 item developed by
Horvath (1984b, 1986) to be used early in the relationships between the 3rd and 5th
session. It was administered at the end of the 3rd session for purposes of this research.
The Working Alliance Inventory targets the client-therapist relationship in a pan-
theoretical approach. (Horvath et al. 1993 p. 255). It was designed to be counseling
theory neutral while operationalizing Bordins description of the three factor working
alliance tasks, goals, and bond (Horvath & Greenberg, 1986). The WAI consists of 36
items, 12 relating to each of the factors of the working alliance. The WAI, client version
has a Hoyts estimate of reliability of .88 for the goal and task subscales, a Hoyts
estimate of reliability of .85 for the bond subscale and a Cronbachs alpha of .93 for the
composite (Horvath & Greenberg, 1986). Items are rated on a Likert-like scale from one
being never to seven being always.
Sample items (Horvath, 1984b)
I find what I am doing in therapy confusing (Tasks)
I am worried about he outcome of these sessions (Goals)
(name of counselor) and I understand each other. (Bond)


DEDICATION
This study is dedicated to the memory of
George A. Bogardus
1920-2001
Martha Lucille Clark Bogardus
1920-1975
Potato and beef farmers who recited epic poetry at our dinner table,
insisted that we attend school even when the crops needed harvested,
instilled a profound love of learning in their children and
kept the house filled with books.


140
PARTICIPANTrevenge is sweetest when he feels what he dished out
FACILITATORor you acted in a way to make him feel bad
FACILITATORlike cheating on him, etc.
PARTICIPANT! told him that we would just separate for a "minute." I
kept him around like we were still "together."
FACILITATORgot it
PARTICIPANT! told him that I was going to date other people
FACILITATORand that was how long ago?
PARTICIPANT! did
PARTICIPANTspring 2001
PARTICIPANTabout feb late jan
FACILITATORdid it feel better when you hurt him? or about the same?
PARTICIPANTliberating
PARTICIPANT! still cared for him but he needed to know that he could
lose me
FACILITATORbut now . although it was liberating in the moment, you
are not liberated now, in fact, trapped
FACILITATORright?
PART I Cl PANTwel 1
FACILITATORcause you said you need to get over your "problem". Or
did I misunderstand?
PARTICIPANTliberating in the sense that I realized that I had the
power to hurt him take the situation into my hands
PARTICIPANTbefore I was the one crying
PARTICIPANTyou are correct
FACILITATORthe question is now do you want to get back with him?
would he? would you? or you think you need to just sort out and move
through your feelings, but move on?
FACILITATORwe probably won't be able to make your world "perfect",
but if you had a magic wand - -how would it be?
PARTI Cl PANTno. yes .not right now. correct


145
American Psychological Association. (1997). Services by telephone,
teleconferencing and Internet: A statement by the ethics committee of the American
Psychological Association, [web document], American Psychological Association.
Retrieved 05/04 2001, from the World Wide Web: http://www.apa.org/ethics/stnt01.html.
AT&T (2001). Glossary of Internet terms, [web document], AT&T Retrieved
06/29 2001, from the World Wide Web: http://www.iatt.net/moreinfor/glossarvaf.html.
AT&T (2001). Glossary of AT&T digital broadband terms, [web document].
AT&T Retrieved 06/29 2001, from the World Wide Web:
http://www.iatt.net/moreinfor/adbglossarvaf.html.
Archer J., Jr., & Cooper, S. (1998). Counseling and mental health services on
campus. San Francisco, Jossey-Bass Publishers.
Attkisson, C. C. & Pascoe, G. C. (1983). Patient satisfaction in health and mental
health services. Evaluation and Program Planning. 6. (Special issue), 185-418.
Attkisson, C. C. & Zwick, R. (1982). The Client Satisfaction Questionnaire:
Psychometric properties and correlations with service utilization and psychotherapy
outcome. Evaluation and Program Planning. 6. (Special issue), 233-237.
Babich, A., Burdine, P. L., Albright, L. & Randol, P. (1976). C.I.T.E.Leaming
Styles Instrument. Wichita, KS: Wichita Public Schools, Murdock Teachers Center
Barak, A. (1999). Psychological applications on the Internet: A discipline on the
threshold of a new millennium. Applied and Preventive Psychology. 8. 231-246.
Barak, A. & Wander-Schwartz, M. (1999). Empirical evaluation of brief group
therapy through an Internet chat room [web document], Haifa University. Retrieved
02/13, 2001, from the World Wide Web: http://contruct.haifa.ac.il/~azy/therapy.htm.
Barlow, G. (2001). Redefining the virtual private network (VPN), [web
document]. Retrieved 08/16 2001 from the World Wide Web:
http ://www. checkpoint. com/products/vpn 1 /vpndef. html.
Beck, A. T. (1978). Beck Depression Inventory. Philadelphia, PA: Center for
Cognitive Therapy.
Beck, A. T., Rush, A. J., Shaw, B. F. & Emery, G. (1979). Cognitive therapy of
depression. New York, NY: Guilford Press.
Beck, A. T., Epstein, N., Brown, G. & Steer, R. A. (1987). An inventory for
measuring clinical anxiety: The Beck Anxiety Inventory. Philadelphia, PA: Center for
Cognitive Therapy.


5
Entering cyberspace, then, disembodies the counselor and the client. In therapy
in cyberspace, the nature of the interaction first deconstructs the everyday givens of the
counselor and client, then the two co-construct a new healing reality through the
therapeutic dialogue. Is that not the crux of psychotherapy helping, guiding,
facilitating, and coaching clients to discover, learn, or experience their story, their inner
dialogue in a new, more self sustaining way? The major mental health professional
organizations (National Board of Certified Counselors, American Counseling
Association, American Psychiatric Association, American Medical Information
Association, American Psychological Association, Commission on Rehabilitation
Counselor Certification) agree that now, in the infancy of Internet counseling is the time
to set the values, ethics and discipline of this new opportunity (NBCC 1997, NBCC 2001,
APA 1997, AMIA 1998, ACA 1999, APA 2001, CRCC 2002).
Virtual Psychotherapy will have as little in common with the theory, context,
content, and outcome of contemporary psychotherapy as contemporary psychotherapy
has with priests and shamans. In the pre-modem or pre-science era, priests and shamans
healed physical, emotional, and spiritual distress based on observations and beliefs about
the natural and supernatural world, using plant materials, astronomical observations,
beliefs about supernatural interventions and such. In the 1990s and 2000s these
ceremonies continue but it is unlikely that Blue Cross Blue Shield or any other third party
payer would assume financial responsibility for a Sufi whirling dervish, a Greek
Orthodox exorcism, a Pentecostal spiritual slaying, an Episcopalian laying on of hands
healing service, a Sunni (Lapland) sweat lodge, a Kiowa medicine wheel, a Lakota
buffalo hide ceremony, Saginaw Chippewa eagle feature ceremony, yogi fire walking


CHAPTER 3
METHODOLOGY
Statement of Purpose
The purpose of this study is to examine the efficacy of Internet counseling. Chat
room counseling was compared with traditional face-to-face counseling. Similarities and
differences were measures for therapist-participant alliance and for outcome. Four of the
multitude of individual differences, gender, ethnicity, personality, and information
processing, that each participant brings to the therapeutic setting, were measured to
determine is any difference in impact can be discerned in the face-to-face or computer-
mediated condition. This chapter presents the research hypotheses, dependent and
independent variables, sample population, procedures for training the facilitators,
procedures for the implementation of the personal growth sessions, instrumentation,
experimental conditions and assignment to conditions, data collection and statically
analysis.
Hypotheses
The study will test the following null hypotheses:
Hoi: There is no significant difference in the client reported quality of the
working alliance when counseling is delivered face-to-face or computer-
mediated regardless of gender, ethnicity, personality style, learning style.
Ho2: There is no significant difference in outcome efficacy when counseling is
delivered face-to-face or computer-mediated regardless of gender,
ethnicity, personality style, or learning style.
Ho3a: There is no significant relationship between the client reported quality
of the working alliance and gender in CM Counseling.
71


80
The advantage of these measure are that they have forms for both the participant
and the therapist providing the opportunity to view the therapeutic relationship through
both lenses. The forms are attractive, well researched and easy to understand and
complete with a minimum of time and effort on the part of the participant. The questions
are non-threatening and non-intrusive while tapping all three aspects of the working
relationship defined by Bordin and fundamental to all therapeutic relationship
instruments examined.
Working Alliance Inventory (Therapist)
The Working Alliance Inventory Form T is the therapist version that assesses the
therapist view of the working alliance across all three components of bond, task
agreement and goal agreement.
Sample items (Horvath, 1984a)
I feel uncomfortable with (bond)
My client and I both feel confident about the usefulness of our current
activity in therapy, (tasks)
and I have a common perception of her/his goals, (goals)
Outcome Satisfaction Questionnaire
An outcome satisfaction questionnaire was developed for this study because
outcome measure reviewed in the literature emphasized medical diagnosis and
symptomatology or were site specific dealing with the mechanics of scheduling
appointments and locating offices. Items for this outcome measure were written by the
principle investigator or adapted from existing instrument where applicable. A
committee of experts reviewed the potential items. A pilot study of the instrument was
conducted at a local community college to gather feedback from students receiving
counseling and from counselors regarding item wording, appropriateness, and face value.
Information from the committee and from the community college study were


96
Outcome Satisfaction
Facilitator scores on the Outcome Satisfaction measure demonstrated statistically
significant for the main effect gender so follow up analysis was conducted. Table 10a
displays the ANOVA outcome while Table 10b presents the means and standard
deviation for the significant main effect.
Facilitators reported that female participants experienced greater overall outcome
satisfaction (mean 15.55, standard deviation 3.7) with their personal growth sessions than
did male participants (mean 18.03, standard deviation 4.4). There was no significant
interaction by condition suggesting that this facilitator perceived gender related outcome
satisfaction did not differ by condition
Facilitators perceived that female participants experienced greater outcome
satisfaction with their personal growth sessions. However, there was no significant
difference in participants report of outcome satisfaction (see Table 5).
Table 13. Source table for dependent variable Outcome Satisfaction (facilitator)
Sources of Variance
Type III Sum
of Squares
df Mean Square
F
Sig.
Corrected Model
338.795
19
17.831
1.140
.324
Intercept
6252.829
1
6252.829399.917
.000
Condition
3.410
1
3.410
.218
.642
Gender
m.186
1
11UU
ill
.009
Ethnicity
.793
2
.397
.025
.975
Academic Learning Style
22.924
2
11.462
.733
.483
Introversion/ Extraversin
1.074E-02
1
1.074E-02
.001
.979
Temperament Learning Style
23.115
3
7.705
.493
.688
Condition by Gender
11.576
1
11.576
.740
.392
Condition by Ethnicity
13.402
2
6.701
.429
.653
Condition by Academic Learning Style
20.864
2
10.432
.667
.515
Condition by Introversion/ Extraversin
27.036
1
27.036
1.729
.192
Condition by Temperament Learning Style
65.180
3
21.727
1.390
.250
Error
1563.530 100
15.635
Total
32911.000 120
Corrected Total
1902.325 119


63
implications for counseling based on type and counseling goal vocational and career,
education and learning, organizational team building and provides guidelines for using
introversion/extraversion (as well as other scales) appropriately in each setting.
Introversion
The trait of introversion is generally associated with a preference for
communicating in writing, working out ideas by reflecting on them, being private and
self contained, and for taking the initiative when a situation or issue is very important to
the person (Myers 1962).
Extraversin
The trait of extraversin is seen in people who are attuned to their surroundings,
communicate verbally, problem solving by talking through issues, and learn by doing or
discussing (Myers 1962).
Measuring Personality Attitudes
While Jung, Briggs, Myers, and McCaully all thought and taught that the
dimensions are dichotomous, several researchers (Mendelson 1965, Girelli & Stake,
1993) examined the scales as continua and suggested that the forced choice format of the
forces the bipolarity artifact, underestimating the true continuum of the dimensions. The
current protocol for scoring the MBTI has keys for calculating the degree of introversion/
extraversin for example rather than regarding them as dichotomous categories. For the
purpose of this study, the scales were treated as discrete traits.
The dimension relevant to this study is Introversion/Extroversion. Livingood
(1995) found that the number of introverts on these (Internet mail lists by MBTI type) is
five times greater than the number of extroverts. However, in the United States at large,


20
Organization of the Study
This study consists of five chapters, an abstract, three appendices, and a list of
references. The abstract and introduction present the Internet and counseling context for
the study describing research issues of the growth and professional concerns about
Internet counseling. The second chapter reviews relevant scholarly literature on social
presence, Internet counseling, face-to-face brief counseling, working alliance measures,
outcome efficacy measures, learning styles and personality traits. The third chapter
describes the structure of the study, characteristics of the participants, dependent and
independent variables observed, measures used, and statistical procedures applied to
analyzing the results of the experiment. Chapter four presents the statistical results and
chapter five discusses the significant results, potential impact to Internet counseling,
limitations of the study, and recommendations for Internet counseling and further
research. The appendices contain forms and measures created for this project, protocol
for facilitator training and sessions, and a sample computer-mediated session transcript.


17
cost- containment means, a strong research effort is needed to support the claims of
counselors and clients for third-party payment.
Research Questions
The following six research questions were examined in this study:
1. Is brief, Internet counseling as effective as brief face-to-face counseling?
2. Does working alliance develop equally well in brief, Internet counseling and in
face-to-face counseling?
3. Does the information processing style (visualizing/verbalizing) of a
participant influence the effectiveness of Internet brief cognitive counseling?
4. Do personality attitudes (introversion/extroversion) of client affect the
efficacy of Internet brief cognitive counseling?
5. Does the ethnicity of the client affect the efficacy of Internet brief
counseling?
6. Does the gender of the client affect the efficacy of brief cognitive Internet
counseling
Definition of Terms
Counseling terms
Learning style the sensory and social process by which an individual acquires,
encodes, stores, and retrieves information, including visual, verbal, kinesthetic, tactile,
social-individual, social-group, expressive-oral and expressive-written (Babich 1976).
Personality Traits as defined by Jung (1923) these are psychological factions of
thinking, feeling, sensing, and intuiting, which interact with attitudes of introversion and
extroversion. Myers (1962) added the constructs of judging or perceiving (cf. MBTI).
Each individual has preferred functions and attitudes that he or she generally prefers to
use to collect information about, and interacts with his or her intrapersonal and
interpersonal environment.


102
Table 23: Means and Standard Deviation for gender variable
Dependent Variable: Working Alliance Inventory goal (therapist)
Gender
Mean
Std. Deviation
Male
14.28
13.864
Female
20.72
8.477
Facilitators thought that participants, regardless of individual difference, showed
greater abilities to formulate and define goals in the computer-mediated condition (M =
19.75, SD =10.17) than in the face-to-face condition (M=18.74, SD = 10.60). Goal
definition is extremely important in evaluating efficacy because unless the goal is rather
specific it is difficult to assess its achievement.
Table 24 Means and Standard Deviation for independent variable condition, dependent
Variable: Working Alliance Inventory goal (therapist)
Condition
Mean
Std. Deviation
Face to face
18.74
10.597
Computer mediated
19.57
10.171
In summary, condition, gender, and academic learning style were the independent
variables that showed statistically significant main effects in the scales evaluated.
Gender by condition was the only significant interaction and occurred in both participant
and facilitator measures. From the participants perspective, visual learners predicted
greater likelihood of seeking computer-mediated mental health services if they a re
needed in the future than did verbal learners. Paradoxically, verbal learners indicated that
they had greater computer and Internet skills than did visual learners. Participants
responses indicated that males were better able to collaboratively develop tasks with their
facilitators to use to achieve their personal growth goal in the computer-mediated


4
client chose to respond accurately. However, in virtual reality one can role play age,
race, gender, physical attributes and try on a vast range of solutions from which to select
practical ideas to apply in his or her social-gravity bound life. The counselor in virtual
sessions will not only be aware that the client may be role-playing but will need to
develop new theory which promotes and capitalizes on a therapeutic world free from
factors that often may actually be the source of the clients distress. This radical new
formulation of therapy may be analogous in the physical sciences to work done in space
in the absence of gravity. Obviously one does not live long in the absence of gravity
without serious physical consequences (e g., loss of bone mass and tissue density).
However, as a special condition to accomplish a specific end (e g., re-growing tissue
more quickly and with less pain) it has therapeutic advantages heretofore unavailable in
theory or in practice. The powerful value of such study is clearly demonstrated by a
global communitys willingness to engaged in the high risk, construction of our third
multibillion-dollar facility for such research the International Space Station (preceded
by Skylab and Mir).
Cyber counseling therapy in the absence of the weight and pressure of social
markers allows a healing space, not a long-term residence for the client. Just as NASA
researchers and their Russian counterparts must experiment and learn about the
weightless environment available in near outer space, mental health researchers must
experiment and learn about the social and relational weightlessness of cyberspace.
Cyberspace then presents the constructionist need for a completely new theory of
counseling, a completely new way of thinking about counseling, not just a new delivery
system.


81
implemented into the final 12 item form developed for participants and 7 item form
developed for facilitators. The facilitator form did not include qualitative questions
found on the participant form.
Students rated their perception of their computer skills and their likelihood of
seeking Internet counseling should they seek counseling in the future. They answered
open-ended questions about what they least liked about computer-mediated
communication as they had experienced it in this study and were encouraged to offer
suggestions, comments, and ideas about the Internet interaction study. Facilitators were
trained in adequate computer skills, as needed, before beginning their work on this
project and were individually debriefed about the other points in end of study interviews.
Myers Briggs Type Indicator Form M (MBTI)
The MBTI is arguably the most researched and most widely used personality
instrument. The Singer-Loomis Type Deployment Instrument (Singer 1996) and Keirsey
Type Indicator (1984/1996) are similar Jungian theory based instruments but less
researched and less often applied. The Keirsey Type Indicator is readily available on the
Internet, although no longer free. The Singer-Loomis is still considered to be a research
tool, and as such not used in applied setting such as business, counseling, and career
development. The strength of the Singer-Loomis is that it is built upon a dynamic theory
of personality growth and change rather than what has been seen as the rather static
typing of the MBTI. The MBTI, however, was used in this study because the
introversion/extroversion scale has consistently been found to have predictive and
discriminative value. The Keirsey and Singer Loomis blend the four scales while the
MBTI is more consistent with Jungs theory that introversion/extroversion is a attitude,
while thinking/feeling and intuition/ sensing are traits. It is the introversion/extroversion


23
real life connection among members is illustrated in the following two incidents. The
WELL community organized a massive medical resource location, medicine delivery,
and member return transportation from India to San Francisco when a former member
who had become a Tibetan nun developed a rare liver condition and was destined to die
in India without this heroic, real time, real cash, real resource, unbidden, but greatly
appreciated massive intervention (28-32).
In another case, a prolific member of the WELL committed Internet suicide, the
act of removing all of his years of comments and conversations written into the fabric of
the community. Alert members of the community called him, assured that he sought and
received professional help, and notified his family and other friends. In the end, the
effort was insufficient and the member committed real world suicide. Rheingold mused
Suicide brings up unusual feelings in any family or
social group. Fortunately, there were one or two
among us who knew exactly how to understand what
was happening to us: a fellow who had struggled with
years of feelings over his brothers suicide was able to
offer wise and caring and credible counsel to many of
us.
There was a real-life funeral, where we brought our
physical bodies and embraced each other and Blairs
family. We were learning how fond we had grown of
Blair, and how his death put a milestone in cyberspace.
Marriages had happened and others had unraveled.
Businesses had started and failed. We had parties and
picnics. But death seems somehow more real, even if
your only participation is in the virtual funeral. How
could any of us who looked each other in the eye that
afternoon in the funeral home deny that the bonds
between us were growing into something real? The
feelings ran just as high during the virtual part of the
grieving rituals as they did during the face-to-face part
- indeed, with many of the social constraints of proper
funeral behavior removed, the Internet version was the
occasion for venting of anger that would have been
inappropriate in the face-to-face gathering. There


This dissertation was submitted to the Graduate Faculty of the College of Education
and to the Graduate School and was accepted as partial fulfillment of the requirements for
the degree of Doctor of Philosophy.
December 2002
M. Harry Daniel
Chairman, Counselor Education
Dean, Graduate School


7
have learned English in a country or culture that places high value on knowing English
and teaches it beginning in first grade.
English as a second language has been identified as a multicultural issue in
counseling. How much greater will this issue become, in a global environment?
Counseling laws, where they exist, tend to confine counseling to the state of the
therapists licensure; however, there are no International constraints. A potential client
can be asked to affirm that she or he lives in the state of the therapists licensure.
However that does not mean that the person does, or if he or she does that he or she lives
in an acculturated community. If a persons English or Spanish appears to be adequate to
the counseling demands, can we assume that the person is keying in his or her comments
directly through the computer, or is the client talking to a typist who enters the
comments, or to a translator who must interpret both sides of the communication
inadvertently and subtly changing each side. Web cam technology offers some solutions,
or hope for solutions to the disembodied and perhaps linguistic problems posed in
Internet counseling. An area of counseling is likely to evolve in the virtual reality model
that is independent of physical and verbal cues.
Virtual reality models and virtual reality role playing have 30 years of history and
refinement from the worlds of virtual gaming and virtual socializing. Fundamental issues
of human presences, viability, efficacy, ethics, limitations, indications, contraindications,
national and international licensing and liability and risks to clients must be thoughtfully
discussed, debated and researched.
Scope of the Problem
Psychotherapists are using the Internet to provide a full range of mental health
services. Powell (1998) surveyed licensed Internet counselors listed on the Metanoia


50
events, cognitive processes and meta cognition. Cognitive templates or schemas are
identified and the client is enabled to change those templates that no longer function in
his or her best interest. Meichenbaum encourages the client to be his or her own folk
scientist and assigns experiments to develop needed skills. He encourages therapists to
use specific examples to identify faulty logic We have found that people often make
certain kinds of errors in the way they look at situations and that these errors in thinking
may contribute to arriving at premature or incorrect conclusions. Its natural to readily
come to such conclusions without even noticing them (p. 193). Logical errors include
all or nothing thinking, seeing possibilities as certainties, dichotomous thinking,
personalization and self blame for negative events, and over generalization. Because this
theory and therapy relies on homework and experimentation by the client to reach his or
her own conclusion, that affect change, it is adaptive to an Internet Counseling
environment.
Gabriel & Holden (lecture reported in Laszlo 1999) developed an Internet
protocol for cognitive behavioral therapy, that looked at theme patterns in text based
sessions. They sough patterns of over generalization as indicated by the use of polar
adjective, excessive self attribution of responsibility, minimizing or maximizing
significant issues, and focusing on negatives (p. 296-297). There does not appear to be
further information on their theory or research but it is intuitively practical.
Ellis developed Rational Emotive Therapy (REBT) in 1955 and changed the name
of this theory and method to Rational Emotive Behavior Therapy in 1993 to include the
Behavioral component of change, which had always been present in his theory (Ellis
1998). He posited emotional and behavioral problems have their source in faulty


157
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86
future use, and computer skill the greater their positive response. The closer a persons
score is on any of the WAI versions or scales is to the maximum, the more positive the
response.
The data was evaluated using analyses of variance (ANOVA), that require that the
independent variable or factor consist of two or more levels and that those levels cover all
possible levels of interest to the researcher (e g., male, female). The levels were
qualitative (e g., face-to-face, computer-mediated personal growth sessions) or
quantitative (e g., MBTI introversion/extraversion). The participant endorsed one and
only one level of each factor. Each independent variable in this study met the criteria.
The critical F value to disprove the Null hypothesis at the .05 confidence level is F (critical
1,123) = 3 .92. The independent factors or variables were condition to which the participant
was randomly assigned, ethnicity, gender, academic learning style, personality attitude,
temperament learning style.
Table 1 depicts the meaningful descriptive statistics for the independent variables
- gender, ethnicity, academic learning style, trait learning style, and attitude and for the
dependent variables working alliance, by scales, outcome satisfaction, predicted future
use, and computer/Internet skill level. The table is organized by experimental conditions,
face-to-face and computer-mediated treatments. Table 2 presents the factors and levels
of each factor used in the analyses of variance.
Participant Dependent Variables Analysis
To evaluate outcome efficacy, participants were asked to evaluate the quality of
their experience in the face-to-face or computer-mediated conditions and their outcome
satisfaction. They were asked to predict if they thought they would be likely to use
computer-mediated counseling in the future. They were asked to describe their comfort


100
participants. Note that the participants did not indicate any significant main effect (see
Table 10) for task development however their responses did produce a significant
interaction (see Table 11) for gender by condition not found in the facilitator scores.
Table 19 Source table for dependent variable Working Alliance Inventory (t) task
Sources of Variance Type III Sum df Mean F Sig.
of Squares Square
Corrected Model
Intercept
Condition
Gender
Ethnicity
Academic Learning Style
Introversion/ Extraversin
Temperament Learning Style
Condition by Gender
Condition by Ethnicity
Condition by Academic Learning Style
Condition by Introversion/ Extraversin
Condition by Temperament Learning Style
Error
Total
1796.808
17
105.695
1.342.182
18699.182
1
18699.182
237.440.000
378.907
1
378.907
4.811.031
463.005
1
463.005
5.879.017
14.136
2
7068
090.914
3.797
1
3.797
.048.827
26.073
1
26.073
.331.566
209.490
3
69.830
.887.451
63.889
1
63.889
.811.370
230.013
2
115.006
1.460.237
134.671
1
134.671
1.710.194
27.713
1
27.713
.352.554
281.066
3
93.689
1.190.317
8111.606
103
78.753
106234.000
121
9908.413
120
Corrected Total
a R Squared = .181 (Adjusted R Squared = .046)
Table 20: Means and Standard Deviation for gender variable
Dependent Variable: Working Alliance Inventory task (therapist)
Gender Mean Std. Deviation
Male 23.97 12.774
Female 29.55 7.149
Facilitators also noted stronger task collaboration in the computer-mediated
condition than in the face-to-face condition. It is intriguing that both facilitators and
participants reported gender differential in this dependent variable although they did not
identify it in the same manner. Gender clearly is a factor which influences process and
outcome efficacy in computer-mediated sessions.


33
business strategy to hire out secure credit card processing than incurring the expense and
risk of doing it in-house.
Mitchell and Murphy (1998) recommend that all e-mail be encrypted but agree
that it may be too anxiety producing to ask of a client seeking professional help to acquire
and learn to use an encryption program (p. 52). E-mail can be encrypted with free or
inexpensive software but it only works if it is installed and used properly. PGP (Pretty
Good Privacy) encrypts both e-mail and files for a one-time cost. The software plugs
in to common email programs such as Endora or MS Outlook, to encrypt files, disks and
existing email on a hard disk. ZixMail is a secure email application, which downloads
free but requires $1 per month payment. Zip-Lip and HushMail are both free secure web
messaging services. Messages remain on the server so they cannot be intercepted.
Nothing is stored on the clients computer or the therapists computer (HON, 1995). The
major concern about the use of encryption software is not the quality and usefulness of
the software, but the misuse or inappropriate use of the software (Smith, 1997).
The electronic security issues, technological failures and access have as long a
history of research and development as do research on therapy relationships and outcome
efficacy (Wright & Greengrass 1987). Electronic security is directly related to ethical
issues of privacy and confidentiality. While news media seem to frequently report
breaches of electronic security, a close examination of recent espionage incidences reveal
that most involve an insider (Lee, Ames, Hansen) who has direct, physical access to the
hard drive, server, stolen laptop, software, encryption/decryption devices or paper files.
Virtual Private Network (VPN) is the concept of using private computers (desktop,


65
consumer satisfaction (Becker et al. 2000, Cialo 1982, Eisen, Leff, & Schaefer 1999,
McCullough 1993, Preston 2000, Treadwiell, Soetikno, & Lenert 2000).
Working Alliance
For several decades, researchers have attempted to isolate the therapeutic method
or technique that was most effective. This research had limited results when the broad
concept the interpersonal milieu of therapy, first introduced by Freud as transference
was examined. Clarkson distills from the literature and her diverse theory training,
five relationships between therapist and client, which strongly inform this study.
Although not all these relationships may exist in any given therapeutic relationship, and
may not be recognized by all theoretically orientations, each is potentially available
within computer-mediated therapy as in the face-to-face work, however it was the first,
the working alliance, with which this study is primary concerned. Identified therapeutic
relationships include
The working alliance as the part of client-psychotherapist relationship that
enables the client and therapist to work together even when the patient or client
experiences strong desires to the contrary.
The transferential/countertransferential relationship as the experience of
unconscious wishes and fears transferred on to or into the therapeutic partnership.
The reparative/developmentally-needed relationship as intentional provision by
the psychotherapist of a corrective, reparative, or replenishing relationship or
action where the original experience was deficient, abusive or overprotective.
The person to person relationship as the real relationship or core relationship as
opposed to object relationship.
The transpersonal relationship as the timeless facet of the psychotherapeutic
relationship, which is impossible to describe, but refers to the spiritual dimension
of the healing relationship. (Clarkson, 1995)


83
Kuder Occupational Interest Survey by college major and occupational scales, the
Strong-Campbell Interest Inventory (now known as the Strong Interest Inventory) by
occupational themes, the Kolb Learning Style Inventory by scales, the Science Research
Temperaments Scale, the Watson Glaser Critical Thinking Appraisal, and lesser known
instruments including the Conflict Management, the Harbaugh (W)holistic Scales, the
Internal-External Locus of Control and the Intolerance of Ambiguity. The body of work
establishes the MBTI construct validity, divergent and convergent validity.
Center for Innovating Teaching Experiences Learning Styles Inventory (CITE)
The Center for Innovative Teaching Experience, Murdock Teacher Center,
Wichita Kansas School District developed the Learning Style Inventory most prevalently
used in education today. The CITE Learning Style Instrument is composed of 45 items
that the respondent scores 4, 3, 2, or 1. A score of 4 on an item means that the respondent
feels the statement is most like me while a score of 1 indicates that the statement is
least like me. Results were calculated for nine subscales, visual language, visual
numerical, auditory language, auditory numerical, kinesthetic-tactile, social-individual,
social-group, expressiveness-oral and expressiveness-written (Babich et al., 1976). For
the purposes of this study, the visual numerical and auditory numerical are thought to be
irrelevant to the counseling context but were analyzed in case they tap symbolic
language. Items were scored for each category and significance or major learning style
is determined by a cut score of 33 on any scale. The split-half reliabilities were .6 or
better for eighty-five percent of the constructs.
Sample items (Babich et al., 1976)
I remember things I hear better than I read (Auditory)
I would rather read a story than listen to it read. (Visual)


18
Working Alliance the therapeutic relationship that develops in the counseling
environment to facilitate success. Three components of the working alliance are the bond
between client and counselor, mutual agreement on the goal of therapy, and mutual
agreement on the tasks of therapy that will accomplish the goal (Bordin 1976).
Computer Terms
Synchronous (antonym asynchronous) means happening at the same time or moving at
the same rate of speed or having the same rate and phase as vibrations (Gurainik 1979).
These are key concepts in Internet communication and refer to the ability of people to
communicate at the same time (synchronous) from any computer in the world or near
outer space or to communicate at different times (asynchronous). Examples of
synchronous interactions are text chat and media chat. Email and bulletin board
discussions are asynchronous. (Suler 1999).
Chat real time, live, or synchronous text conversation between two or more people
located at a computer keyboard anywhere on the planet or in near outer space. (Young,
1998)
Cyberspace a term coined by science fiction writer William Gibson (1984) to describe
the space that exists between people, computers, satellites and phone lines
E-mail generally one to one written letters but courtesy copies, blind courtesy
copies, and group mailing are also common (Young 1998).
Encryption applying mathematical algorithm to plain text to produce apparently
unintelligible text for security purposes during transmission (Smith 1997).
Telehealth/telemedicine developed originally by NASA (2001) in the early 1960's to
provide health care and monitoring for astronauts, beginning with Project Mercury. It


ACKNOWLEDGMENTS
I wish to express my gratitude to my doctoral committee, James Archer, Jr., Harry
Daniels, David Miller and Linda Shaw who permitted me to develop research in a
fast-growing and little-researched aspect of counseling. Doug Johnson, the WebCT
system administrator was an invaluable resource, problem solver, and unexpected source
of encouragement. James Watson and Alan Pappas provided access and administrative
support at Santa Fe Community College.
Robert E. Groble M.D. provided the financial backing for this project and granted
me leave from office duties to complete it. Kristopher Groble, Loren Groble, and Samuel
McFadden interfaced with the facilitators to make their work easier. They ran errands,
and provided data entry, proofreading, and other computer, management, and clerical
services.
I want to thank the graduate students who facilitated this experiment. Without
them, I could not have completed project of this magnitude. Daniel Pekich, rehabilitation
counseling, and Heather McWilliams, mental health counseling each worked with a large
number of participants and headed the team of facilitators at the University of Florida and
Santa Fe Community College respectively. Lakisha Scott, rehabilitation and mental
health counseling; Lamandra Jenkins, school counseling; Anjanette Todd, school
counseling; Wendy Marsh, rehabilitation counseling; Angela Falcone, mental health
counseling; and Lesley LeBaron, marriage and family counseling were seriously
committed to the students they facilitated and were dedicated to working with a protocol
and theory that might not have matched their own preference. They brought a broad
IV


BIOGRAPHICAL SKETCH
Martha Lana Bogardus Groble was bom near Meadville, Pennsylvania on
September 4, 1947. She graduated from Cochranton Area Junior Senior High School in
May 1965 and attended Indiana University of Pennsylvania where in January 1969 she
earned a bachelors degree with honors in Education (majoring in mathematics). She
taught 7th and 8th grade mathematics at Roosevelt Jr. High School, Altoona, Pennsylvania
before enrolling in the University of Oklahoma where she earned a masters degree in
Anthropology in 1971. She conducted or participated in academic fieldwork in southeast
Alaska; the Yucatan peninsula; San Jose, California; and Sierra Leone, West Africa. She
worked in education, collections, and exhibits at the Stovall Museum of Science and
History; the Jacksonville Museum of Science and History; the Riley County, Kansas
Historical Society; and the Kansas State University Planetarium. During her time in
Kansas, she taught physics and anthropology at Kansas State University. After a
parenting hiatus of several years, during that she was active in school, community and
volunteer service, she established and worked in a psychiatric practice in 1983. In 1986,
she enrolled in the University of North Florida and earned a masters degree in
counseling psychology in 1989. She earned her license in mental health counseling in
1992 and continued to work in the psychiatric practice. In 1993, she was awarded a
Veterans Administration contract for vocational rehabilitation counseling. To enhance
her ability to provide excellent services to her veteran clients, she enrolled in the
University of Florida, College of Education, Department of Counselor Education to earn
160


101
Table 21 Means and Standard Deviation for condition variable
Dependent Variable: Working Alliance Inventory task (therapist)
Condition
Mean
Std. Deviation
Face to face
27.74
9.049
Computer mediated
28.65
9.172
Working Alliance Inventory Goal (therapist)
Again, as in the task sub scale, the facilitators reported significant main effects for
the variables condition (F = 4.01, p = .048) and gender (F= 7.34, p = .008) in the goal sub
scale (Table 22). Means and standard deviation for condition and for gender are reported
in Table 23.
Table 22 Tests of Between-Subjects Effects
Dependent Variable: Working Alliance Inventory goal (therapist)
Sources of Variance
Type III Sum of
Squares
df
Mean
Square
F
Sig.
Corrected Model
2412.598
17
141.918
1.402
.151
Intercept
7347.594
1
7347.594 72.611
.000
Condition

i
409.032
4.012
.048
Gender
742.524
1
imm
7.338
m
Ethnicity
53.847
2
26.924
.266
.767
Academic Learning Style
7.147
1
7.147
.071
.791
Introversion/ Extraversin
37.032
1
37.032
.366
.547
Temperament Learning Style
91.743
3
30.581
.302
.824
Condition by Gender
147.608
1
147.608
1.459
.230
Condition by Ethnicity
318.927
2
159.463
1.576
.212
Condition by Academic Learning Style
186.915
1
186.915
1.847
.177
Condition by Introversion/ Extraversin
6.964
1
6.964
.069
.794
Condition by Temperament Learning Style
468.334
3
156.111
1.543
.208
Error
10422.757
103
101.192
Total
57318.000
121
Corrected Total
12835.355
120
a R Squared = .188 (Adjusted R Squared = .054)
Female participants were perceived to have or at least to have communicated
greater session goal definition (M=20.72, SD = 8.48) than did males participants
(M=14.28, SD =13.86)


12
mental heuristic. Meta-cognitions are ways of thinking about and controlling cognitive
processes. Scarlett OHaras tomorrow is another day or little orphan Annies the sun
will come out tomorrow are meta-cognitions, cognitive processes or templates that
automatically inform that believer to ignore todays disappointments, fears, worries, and
concerns because they were gone tomorrow. Cognitive structures or schemes are
templates that are pervasive, readily accessible, and reflect personal themes.
Each theory of psychotherapy has generated techniques or procedures, that use,
operationalize, and/or apply the theory in concrete situations with particular clients. Beck
and his colleagues (Beck 1979) emphasized that cognitive behavioral therapy is
collaborative work, which begins with rapport. To develop this working relationship,
they recommend that a good base for building of rapport is simple courtesy not
keeping the patient waiting, remembering important facts about him, and giving a
sincerely warm (but not effusive) greeting. Maintaining eye contact, following the
content of the patients talk, trying to infer and reflect the patients feelings, and phrasing
questions and comments diplomatically help to build rapport. The choice of words and
labels is important (p. 53). For example, non-productive ideas is preferable to
neurotic, sick, or irrational thinking. The working relationship in cognitive
behavior therapy, however, is more than rapport building, which can be accomplished in
a hierarchical relationship as well as in a collaborative relationship. In a cognitive
behavior therapeutic relationship, the therapist and patient work together to determine
how and what the patient thinks, the basis for such thinking, and the practical benefits
and losses that result from such thinking. The patients unique contribution to this
collaborative effort is to provide the raw data for this inquiry, that is, to report his


41
Telephone. Teleconferencing, and Internet: A statement bv the ethics committee of the
American Psychological Association). In 1998 the American Medical Informatics
Association published Guidelines for the Clinical Use of Electronic Mail with Patients.
The American Counseling Association published Ethical Standards for Internet
Counseling in 1999. The International Society for Mental Health Internet and the
Internet Health Coalition each published their standards in 2000. In 2001, the American
Psychiatric Association published American Psychiatric Association principles for
medical ethics with annotation especially applicable to psychiatry.
In a pilot study, Mitchell and Murphy (1998) examined the email therapeutic
relationship with one client who had engaged in over 100 transactions with the therapists.
In 1995, the researchers had set up a pilot counseling site on the local computer bulletin
board service. They limited access to counseling services to two thousand members.
The services offered were the Virtually Solve It worksheet (VSI) an Internet form design
to help the potential client explore and externalize the problem. They introduced therap-
e-mail and Ask PATtYQ which stood for Professional Answer To Your Question. In
1998 they interviewed the one client chosen for qualitative response to issues being
debated by the National Board of Certified Counselors committee on WebCounseling
ethics security issues, physical absence, emergency situations, technological failure,
therapeutic relationship/efficacy and access.
Credential Validating Referral Sites
Reliability, credibility and freedom have been the core values of Internet
developers almost since its inception and certainly, since, it became available to the
public. Switzerland is home to two of the primary Internet regulatory bodies, the WWW
Consortium and Health On the Net Foundation http://www.hon.ch/ @HON. The W3


30
to security breaches at their origin and at their destination. In transit, the message
consists of binary code that has been broken into several packets each of which travels
the Internet independent of the other. At the destination, they are reassembled and
checked for completeness.
Security should be applied at each end point where the message is complete and
readable but the counselor can only control his or her end of the communication. It
seems obvious that therapy should not be conducted from the clients employers
computer or from a public computer (library, computer caf, etc.). Ironically, these sites
may be the clients only Internet access. Law and legal intervention cannot secure
wireless connections to the Internet. Hardwired cable modems or DSL cables are also at
risk because they establish a permanent address for the computer access rather than a new
one with each dial up making the connect susceptible to deliberate attack. Dial up
connections are vulnerable to disruption of service. The client and therapist each have to
be responsible for common sense and security on their respected ends of the transmission.
Grohol (2001), who credits himself with creating the term e-therapy, claims that
e-therapy is more confidential and secure than traditional psychotherapy citing thin
walled clinics, and patient charts available to clerical personnel as evidence of lack of
security in a traditional office or clinic. Grohol does have a point to the extent that unless
a therapist sound proofs his or her therapy room, encrypts all telephone calls to
patients/clients, and checks the office regularly for surveillance devices, does his or her
own transcription, copying and filing, and so forth, most Internet psychotherapy is as
secure as its face-to-face counterpart. Workers Compensation required that all case notes
relevant to the injury be copied and submitted with the request for payment. How secure


TABLE OF CONTENTS
Page
DEDICATION iii
ACKNOWLEDGMENTS iv
ABSTRACT x
CHAPTER
1 INTRODUCTION 1
Scope of the Problem 7
Theoretical Framework 9
Statement of the Problem 14
Purpose of the Study 15
Need for the Study 15
Rationale for the Study 16
Research Questions 17
Definition of Terms 17
Counseling terms 17
Computer Terms 18
Organization of the Study 20
2 REVIEW OF LITERATURE 21
Internet Counseling Basic Constructs 21
Social Presence 22
Mutual trust or trustworthiness 28
Internet Counseling Issues 29
Website Security 29
Legal Considerations 34
Modalities 35
Telehealth/Telemedicine 35
E-mail 35
Chat/Conferencing 36
Multi-modal 39
Unidirectional Information Only 40
Guidelines for Ethical Practice of Internet Counseling 40
vi


43
major American based mental health Internet research, development and self regulating
organization. Membership and use of the ISMHO logo on a web site is open to any one,
professional, consumer or other, who is interested in the development of mental health
resources on the Internet, for a modest annual membership fee. There is no site
evaluation or monitoring such as @HON uses. The goals of these organizations,
however, are not necessarily congruent with those of the professional organizations. For
example, the goal of the WebPsych Partnership is to ensure a high quality of Members
sites and reduce unnecessary competition and harmful in-fighting. In fairness, it does
seem to be focused on promotion of web sites and accuracy of web sites rather than
interaction with clients or other persons seeking mental health information.
Ainesworths web site, http://www.metanoia.org. was organized in 1995 and
remains one of the primary resources for information about mental health resources,
counselor referral and information. She is a consumer report organization. She
adamantly does not hire therapist or market services. Her listings are free, but the e-
therapist must meet criteria that includes having a web site which she evaluated with
@HON standards, communicating personally with individuals, personalizing help to
these individuals, and communicating with individuals through the Internet. She will not
list any sites where services are not offered by a credentialed professional
psychotherapist.
There is a profusion of sites and listings that do not require professional criteria
for inclusion, but do have some criteria. Mental Health Resource with Leonard Holmes
Ph.D. purports to be your guide to over 700 sites; however, these sites include related
professions such as law and unrelated topics such as aliens. The criteria to list with this


70
questions need to be explored. There are several technologies that can be used virtual
reality, web-cam live transmissions, individual written messages (email), public written
messages (bulletin boards), and live written messages (chat rooms). The Internet lends
itself to group interaction, but individual intimacy is also well represented. The scope of
this study was confined to individual therapy in a live (synchronic) written format. The
individual differences the participant brings to the personal growth computer-mediated
sessions were compared to those that they bring to traditional face-to-face sessions.


LIST OF REFERENCES
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144


97
Follow up analyses were conducted (Table 14) and found that facilitators felt that male
participants experienced less outcome satisfaction (M = 18.03, SD =4.39) than did female
participants (M = 15.55, SD = 3.70).
Table 14 Means and Standard Deviation for gender variable
Dependent Variable: Facilitator perceived outcome satisfaction
GENDER
Mean
Std. Deviation
Male
18.03
4.387
Female
15.55
3.696
Working Alliance Inventory total (therapist)
Analysis of variance for dependent variable, working alliance inventory (f) total
score, a composite of bond, task, and goal, produced significant the main effects for
gender (F= 7.11), p = .009).
Table 15. Source of Variance Table Dependent Variable: Working Alliance
Inventory total (therapist)
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F
Sig.
Corrected Model
11899.169
17
699.951
1.190
.286
Intercept
223760.842
1
223760.842 380.508
.000
Condition
1812.589
1
1812.589
3.082
.082
mm
5176.639
I
5178.639
mm

Ethnicity
268.679
2
134.339
.228
.796
Academic Learning Style
20.833
1
20.833
.035
.851
Introversion/ Extraversin
260.169
1
260.169
.442
.507
Temperament Learning Style
682.333
3
227.444
.387
.763
Condition by Gender
1660.391
1
1660.391
2.824
.096
Condition by Ethnicity
552.180
2
276.090
.469
.627
Condition by Academic Learning Style
336.556
1
336.556
.572
.451
Condition by Introversion/ Extraversin
.646
1
.646
.001
.974
Condition by Temperament Learning Style
1337.318
3
445.773
.758
.520
Error
60569.938103
588.058
Total
1195491.000121
Corrected Total
72469.107120


Copyright 2002
By
Martha Lana Bogardus Groble


133
*Meichenbaum, D. (1988). Cognitive-behavior modification workshop. Boston,
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*Suler, J. (1997). Text-talk: Psychological dynamics of online synchronous
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Required Reading College Student Counseling
Archer Jr., J. & Cooper, S. (1998). Counseling and mental health services on
campus. San Francisco, Jossey-Bass Publishers.
Cooper, S. & Archer Jr., J. (1999). Brief therapy in college counseling and mental
health. Journal of American College Health. 48 (July). 21-28.
Murphy, M. C. & Archer Jr., J. (1996) Stressors on the college campus: A
comparison of 1985 and 1993. Journal of College Student Development. 37 (1), 20-28.
Steenbarger, B. N. (1992). Intentionalizing brief college student psychotherapy.
Journal of College Student Psychotherapy. 7 (2), 476.
Wilson, S. B. (1978). Cognitive intervention in the normal developmental
problems of young adults. Journal of College Student Personnel. 29 (March!. 136-140


34
laptop, mainframe or server), firewalls, public servers, the Internet and the clients
personal computer (Barlow 2001, Fratto 2000).
Certification authority issue digital signatures after performing background
checks to assure that the company certified is what it claims to be. The personal digital
signature certificate verifies that the user is who he or she claims to be. Loss or misuse of
a digital signature certificate has serious consequences, comparable to loss or misuse of a
passport. A digital signature is also analogous to a business or occupational license and
bonding.
Legal Considerations
State licensure and states rights are the key legal issues in Internet psychotherapy.
Federal and state laws regulate Telemedicine (Congress 1997, HCFA 1996, HCFA 1999).
Interestingly, both California and Minnesota have passed laws allowing reimbursement
for telehealth services (Jones 1996a, Jones 1996b). California (Maheu 2001) has also
passed an Internet psychotherapy law restricting practice to in-state clients. Case
Managers, rehabilitation counselors, and nationally certified counselors in states without
licensure may be relatively safe practicing under their national certification. There is
ultimately no way to know if the person with whom the therapist is communicating is
physically located in a state or nation where the therapist has a license or certification.
As a result, much of the experimental research on Internet psychotherapy is being
conducted in Israel (Barak 1999, Barak & Wander-Schwartz 1999), Australia (Reid 1994,
Smith 1997), and Canada (Murphy & Mitchell 1998, Mitchell & Murphy 1998).
Dunaway (2000) discusses both jurisdiction and malpractice insurance issues
The potential for out-jurisdiction counseling is another hurdle faced by e-therapy. State
licenses restrict providers to practice within a state, but patients on the Internet can reside


109
clinical populations, and geographically or situationally remote populations who have
greater dependence on telecommunication for health care.
In retrospect, a survey measure should have been developed to appraise the
participants current Internet usage. Areas to be assessed would include type of Internet
provider service (IPS), number and names of listserv membership, number and name of
use group memberships, frequency of chat room use, frequency of bulletin board use,
number and nature of (personal, vendors, business) email use, knowledge about and use
of search engines. It is an adage of social psychology that the best predictor of fixture
behavior is current behavior, therefore it would be instructive to see how the participants
are currently using the Internet rather than or in addition to asking them to predict future
use of Internet counseling, as was done is the outcome satisfaction questionnaire. It is
assumed that the computer and Internet competence of this sample population is probably
greater than that of the general American population and population of potential clients.
Brief therapy and 50-minute therapy sessions have been demonstrated to be
effective in face-to-face counseling. However, these time frames may or may not be
equally effective in Internet counseling because speaking is generally accomplished faster
than typing. If a person has difficulty producing speech, it is probably part of the
problem for that he or she is seeking help. The same is not true if a person has difficulty
typing quickly, concisely and/or correctly. Dial up ISPs have an annoying habit of
disconnecting that steals precious time from a session. In this study, the time frame was
held constant for the two conditions. This may have compromised the effectiveness of
the Internet condition.


87
and skill level with using a computer and using the Internet. To allow the researcher to
examine the process efficacy of these sessions in the two conditions, participants
answered questions about their total evaluation of the working alliance they co-created
with their facilitator.
Table 1 Descriptive Statistics for Dependent Variables by Conditions
Variables
N
Minimum Maximum
Mean
Std.
Deviation
FACE-TO-FACE CONDITION
WAI Task (client)
59
7
44
32.88
8.748
WAI Bond (client)
59
14
60
46.00
10.609
WAI Goal (client)
59
2
36
25.05
8.330
WAI Total (client)
59
23
140
103.93
24.676
Satisfaction (participant)
59
7
27
12.64
4.877
Computer Skill participant)
59
2
7
4.00
1.218
Predicted future use (participant)
59
0
3
.95
.705
WAI Task (therapist)
58
-4
42
27.74
9.049
WAI Bond (therapist)
58
30
60
49.31
8.217
WAI Goal (therapist)
58
-14
33
18.74
10.597
WAI Total (therapist)
58
17
127
95.79
25.360
Satisfaction (therapist)
58
8
23
15.83
3.738
COMPUTER-MEDIATED CONDITION
WAI Task (client)
64
11
44
31.27
8.016
WAI Bond (client)
63
23
60
45.67
8.160
WAI Goal (client)
63
3
36
24.13
7.722
WAI Total (client)
63
52
137
101.22
21.372
Satisfaction (participant)
63
7
24
13.76
4.294
Computer Skill participant)
63
2
10
4.27
1.096
Predicted future use (participant)
63
0
2
.70
.687
WAI Task (therapist)
63
2
44
28.65
9.172
WAI Bond (therapist)
63
34
60
48.86
7.118
WAI Goal (therapist)
63
-8
36
19.57
10.171
WAI Total (therapist)
63
29
137
96.84
24.022
Satisfaction (therapist)
64
7
25
16.42
4.227
The inventory subscales indicated the strength of the personal relationship (bond),
the mutual creations of tasks, which would lead to accomplishing the goal set for these


148
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Implications and Recommendations
Research
The obvious implication of this study is that computer-mediated counseling is a
viable mode for providing mental health services, and in some dimensions surpasses
face-to-face counseling in effectiveness. Furthermore, there is s preliminary evidence
that there are significant individual differences that need to be explored to determine who
is most likely to benefit from computer-mediated counseling and who should be referred
to face-to-face counseling. The suitability of a potential client and the appropriateness of
computer-mediated
With research-based information, including results in this study, screening
procedures can be developed that consider not just the presented problem but also the
characteristics of the client who is seeking computer-mediated mental health services.
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Isolated clients, however, may not have a choice of services. For these clients, the
therapists awareness of individual differences can be used to maximize the effectiveness
of computer-mediated counseling even when in the best of all possible situations, face-to-
face counseling may have been ideal.
This study addressed only individual counseling. Research must be designed and
conducted to evaluate the potential for Internet group therapy, that actually appears to be
the most prevalent format in current usage.
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54
and be referred for appropriate care or encouraged to return home for care. This is not to
suggest that college students do not have serious mental health issues and concerns but
rather that they are most likely to have the personal talents and resources to maintain
functioning through personal crises and while seeking counseling services available.
Wilson (1978) addressing common developmental problems of career direction,
sexuality, belief clarification and separation from parents, went so far as to suggest
classroom and resident hall intervention would provide cognitive interventions by
providing problem solving development. Archer and Cooper (1998), Pinkerton and
Rockwell (1994) and Steenbarger (1992) have applied the tenets of brief therapy to the
target population of this study. Although each of these researchers found that there is
resistant on the part of colleagues to endorse brief therapy, their research and the research
of others found brief therapy to be both effective and efficient in campus counseling and
mental health counseling.
Luckey (1996) and Christmas (2000) addressed the use of Internet communication
modalities with college students. Indiana University of Pennsylvania,University Health
Services (Luckey 1996) used the Internet for communication and data base processing.
Because this work was written early in the public access to the Internet, its application
appears to be limited to communicating with and retrieving data from colleagues rather
than direct student services. However, four years later, Duke University (Christmas
2000) was using unsecured E-mail (password protection only) with the student body
population and had established guidelines for interaction with students by email. These
guidelines specify the exclusion of sensitive information that North Carolina state law
requires a health care provider to present to a client in person (e g., positive HIV lab


132
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Required Reading Study Protocol
These articles must be read prior to beginning tow ork on this project so that we
are all working from a common body of information. You may borrow the researchers
copies. All articles are available in the Educaiton Library, Library West, the Health
Science Library, on the Internet, or are included (*) in your manual. You are also
welcome to read the entire dissertation proposal but that is certainly not required or
necessary. You may download the WebCT manual from http://www.webct.ufl.edu but
this is not necessary and it contains a great deal of information you do not need.
Colon, Y. (1994). Chatter!er ling through the fingertips: Doing group therapy
Internet [web document]. Women and Performance Retrieved 2/15, 2001, from the World
Wide Web: http://www.echonyc.com/~somen/Issuel7/public-colon.html.


48
Another disadvantage is face validity on the Internet. A well-designed site may
have powerful face validity that speaks volumes for the competence of the web designer
but say nothing about the credentials and skills of the counselor. With a population
accustomed to visual pleasure from screens television, movie, electronic games, and
computer monitors, the design may allow totally unqualified, perhaps even harmful
counselors to gamer large practices. What you see, may not be what you get.
Anonymity, abandonment, and physical absence are closely related. The client
and the therapist for that matter can disguise his or her identity on the Internet. This
reality needs to be built into Internet counseling theory as the modality evolves beyond
applying traditional modes to the new media. The client could also disguise his or her
identity in person although it is more difficult if payment involves insurance policies or
credit cards. Abandonment is a serious risk on the Internet, while it less likely to occur in
a physical practice setting. Traditional clients may feel abandoned when their treatment
is completed, when they are referred to another mental health care provider when these
issues required different skills or training, or, in a clinic setting where the counselor turn
over may be high; however physical sites rarely just disappear the way web-sites do.
Some argue that no interpersonal bond in the cyberspace can replace actual physical
presences (Plant, 1996).
Cognitive Behavioral Counseling Models
Cybercounseling is not limited to one or a few theories or therapeutic models of
counseling. Researchers have studied family (Oravec 2000), self help (Storm & Moreggi
1998), group (Barak & Wander-Schwartz 1999, Colon 1994, Suler 2000), and brief
cognitive (Edelstein 1996, Palmer & Ellis 1995, Ellis 1996), therapies conducted in
cyberspace. This study, however, will apply the brief cognitive behavior therapy model


89
To further analyze the relationship between academic learning style preference
and predicted use, follow up tests were applied. For this variable, the lower value
indicates preference and the higher the score indicates negative responses.
Table 3 Source Table Dependent Variable participant predicted future use of
computer-mediated counseling
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
7.673
17
.451
.897.580
Intercept
15.869
1
15.869 31.520.000
Condition
.280
1
.280
.556.457
Gender
.319
1
.319
.633.428
Ethnicity
6.576E-02
2
3.288E-02
.065.937
Academic Learning Style
2141
1
2,141
4,253.042
Introversion/Extraversion
8.222E-04
1
8.222E-04
.002.968
Temperament Learning Style
1.139
3
.380
.754.522
Condition by Gender
2.739E-02
1
2.739E-02
.054.816
Condition by Ethnicity
.319
2
.159
.317.729
Condition by Academic Learning Style
.113
1
.113
.224.637
Condition by Introversion/ Extraversin
.606
1
.606
1.204.275
Condition by Temperament Learning Style
.309
3
.103
.205.893
Error
52.360
104
.503
Total
142.000
122
Corrected Total
60.033
121
Table 4 displays the resulting means and standard deviation. Those who use a visual
learning style predicted that they would be more likely to seek computer-mediated
counseling should they need counseling in the future (M = .56 SD = .58), consistent with
the study hypothesis that visualizers would be more likely to seek computer-mediated
counseling than verbal or auditory learners (M = .89, SD = .72).
Table 4. Means and Standard Deviation for Significant Main Effect Academic Learning
Styles; Dependent Variable Predicted Future Computer-Mediated Counseling Use
Academic Learning Style Preference
Mean
Std. Deviation
Visual learners
.56
.583
Verbal learners
.89
.720


149
Feeg, V. (1998). Revisiting ethics in a managed care era. Pediatric Nursing, 24
(5), 407-408.
Fink, J. (1999). How to use computers and cyberspace in the clinical practice of
psychotherapy. Northvale, NJ: Jason Aronson Inc.
Fish, L. S. & Busby, D. M., (1996). The Delphi method. Research methods in
family therapy. D. H. Sprenkle & S. M. Moon. New York, NY: The Guilford Press: 469-
482.
Fratto, M. (2000). Multisite firewall management not enterprise-ready, [web
document] Network Computing Retrieved 08/15 2001, from the World Wide Web
http://networkcomputing.com/shared/printArticle7article.. ./1106flfull.html.
Furhmann, C. (2000) HealthPlace.com: your home for peace of mind [web site].
Concerned counseling. Retrieved 08/15 2001 from World Wide Web,
http ://www. concemedcounseling. com/index, html.
Gallagher, T. (2002). Temperament definitions: A quick reference to Jungian/
temperament typing [web document], Bomtoexplore.org. Retrieved 05/07/2002, 2002,
from the World Wide Web: http://bomtoexplore.org/temdefs.htm.
Gaston, L., Marmar, C. R., Thompson, L. W. & Gallager, D. (1988). Relation of
patient pretreatment characteristics to the therapeutic alliance in diverse psychotherapies.
Journal of Consulting and Clinical Psychology. 56. 483-489.
Gaston, L. (1991). Reliability and criterion-related validity of the California
Psychotherapy Alliance Scales Patient version. Psychological Assessment. 3. 68-74.
Gaston, L., Marmar, C. R., Thompson, L. W. & Gallager, D. (1991). Alliance
prediction of outcome beyond in treatment symptomatic changes psychotherapy
progresses. Psychotherapy Research. 1. 104-112.
Gibson, W. (1984). Neuromancer. New York, NY: G. P. Putnams Sons.
Girelli, S. A. & Stake, J. E. (1993). Bipolarity in Jungian type theory and the
Myers-Briggs Type Indicator. Journal of Personality Assessment. 60 (2), 290-301.
Greenson, R. R. (1965). The working alliance and the transference neurosis.
Psychoanalysis Quarterly. 34. 155-181.
Grohol, J. M. (1996). Beware! [web document], PsychCentral. Retrieved 07/18
2001, from the World Wide Web: http://www.grohol.com.


16
conducted an Internet support group symposium at their annual convention. Barak and
Wander-Schwartz (1999) report one of the only studies of Internet therapy. They
describe their study as preliminary, warned that its findings should be interpreted with
caution and called for intensive research. Several professional and scientific questions of
relevance include: Is Internet therapy useful, beneficial, satisfactory, and efficacious? Is
Internet therapy harmful? Does Internet therapy immunize potential clients to effective
face-to-face treatment? Is Internet therapy a technology placebo? Is Internet therapy
snake oil? Do the personality traits of the client influence the effectiveness of Internet
counseling? Is the Internet, as one author suggests, revenge of the introvert? Is a
visual learning style more conducive to effective Internet results than a verbal learning
style? Does the physical isolation of computer-mediated psychotherapy hamper the
success for clients with social group learning style preference? These are but a few of the
questions that need to be considered, especially if the cyber client is to be provided with
appropriate services, the psychotherapist is to remain in compliance with his or her
professional ethics and credentials, and if the insurance industry is to recognize and
reimburse Internet therapy.
Rationale for the Study
This work contributes to the foundation for the lower end technology interface. It
will benefit counselors who wish to work well and ethically Internet. With this and
similar research, counselors will have tools to determine which clients are best served by
Internet counseling, and which clients need to be seen face-to-face. It will benefit clients
who are geographically or situationally isolated from counseling services to be able to
make an informed decision about Internet counseling. Since the federal government
health benefit program has long supported some forms of telehealth and telemedicine as a


CHAPTER 1
INTRODUCTION
At the dawn of the 20th century, the fledgling professions of psychiatry,
psychology and counseling were beginning. As the 21st century begins a radically
different service delivery method, which may in fact generate a radically new helping
profession, is occurring. The current world population of Internet users is estimated to be
around 349 million and growing (Stubbs 2000). A segment of these users are accessing
mental health services variously known as Telecommunications, Telehealth, and
Telemedicine. Telecontact, between a mental health provider and a mental health
consumer, may simply be a plain old phone call, to reassure a patient that his or her
medication has been called into the pharmacy; a copy of an e-mail of a typical interaction
with a troublesome relative, which records the transactions while they are fresh, for
processing in the next scheduled therapy session; peer moderated bulletin board support
groups; video conferencing to train parents how to care for children with seizure
disorders; live, interactive Internet dream work with a renowned dream therapist; or a
very complex, surrealistic virtual reality counseling world. Computer-mediated
counseling is in its infancy. However the generic and programming code necessary to
bring it to maturity is already in place for interactive, graphic (sound, visual, and
animated) virtual worlds where clients can choose avatars or symbols to represent
themselves and to characterize the psychotherapy issues salient to their needs.
1


Logistics
Recruiting Participants:
Researcher contacts instructors of undergraduate classes and get permission to
recruit in their classes. Researcher recruits in classes giving brief description and having
volunteers fill out a contact sheet and a signed consent. The volunteer is also given a
copy of the informed consent.
Scheduling Participants:
Researcher or trained assistant will randomly assign the participant to one
condition or the other. XXX will assign the code (to keep things simple since he has
already begun facilitating). The code takes the form of two or three letters (the initials of
the classroom instructor), four digits (unique ID), and two letters (facilitators initials).
Therefore, LMCxxxxDP is a student in Lauras class with Dan for a facilitator. Use the
code not the participants name on all paperwork and tapes. Once you have the contact
sheet, contact your participant and arrange a mutually agreed upon time to meet. Be
prompt or early. Record all contact and results on your tracking sheet (especially
answering machine messages and no shows).
FACE to FACE CONDITION The facilitator will contact the counselor education office
to schedule a room for the face-to-face session. The facilitator will meet the participant
outside the lab area, introduce him or herself and lead the participant to the assigned
room (rooms will change with each appointment due to availability). Be sure you have
gotten the key from the office, unlocked the room and checked for furniture placement
and cleanliness before the participant arrives. These sessions are to be taped to keep the
conditions equal and to evaluate adherence to protocol. Tapes will be provided. Let me


PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING
By
MARTHA LANA BOGARDUS GROBLE
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
2002


107
computer-mediated counseling when process factors are compared was partially
disproved with regard to gender, task and bond.
Hypothesis II The null hypothesis that there is no difference between face-to-face and
computer-mediated counseling when outcome satisfaction is compared was disproved for
gender as viewed by the facilitator.
Hypothesis HI The hypothesis that a gender differential affects efficacy in counseling in
general and between face-to-face and computer-mediated counseling was supported on
several measures. From the facilitators perspective, gender affected outcome
satisfaction, with men reporting greater outcome satisfaction regardless of condition and
greater task congruity with their facilitators in the face-to-face condition. This is contrary
to expectation because the previous research literature suggested that men are less willing
to seeking counseling. Therefore, it was hypothesized that males would be more
comfortable with and more successful in the computer-mediated condition. Results of
this study suggest that although men are less likely to seek counseling as previously
reported, when they do seek counseling they prefer it to be face-to-face.
The study indicated that males were less willing to engage in even mild
counseling or personal growth sessions than females, even when extra credit in their class
was offered. Eighty eight males initially expressed interest by completing the contact
sheet and informed consent during the classroom recruitment, however only twenty nine
or 33 percent actually participated and completed the project in contrast to 42 percent of
females. Peer pressure may have led students to sign up for the project in the presence of
their instructor and classmates but to decline when individually contacted. Regardless of
influences on participation and completion, males consistently produced results


range of counselor training, personal interest, and racial diversity to the performance of
this research.
I appreciate the instructors who permitted me to use precious class time to recruit
participants and who, in most cases, supported my effort by providing the added
incentive of extra credit to their students Laura McCarthy, Dawn Snipes, Michelle
Murphy, Kitty Fallon, Natalie Arce, Kim Fugate, David Marshall, Keith Carodine, Alan
Pappas, Michael Smith, Joyce Orr, and Paul Stem. I would be remiss if I did not
acknowledge all of the participants who shared issues that were sincere and intimate to
them with their facilitators so that we could learn more about the counseling process and
outcome in cyberspace.
v


153
Maclnnis, D. J. & Price, L. L. (1987). The role of imagery information
processing: Review and extensions. Journal of Consumer Research, 13,473-491.
Maes, P. (1995). The ALIVE system: Wireless, full body interaction with
autonomous agents. Cambridge, MA: Massachusetts Institute of Technology Media
Laboratory.
Maheu, M. (2001). Telemedicine update (Vol. 2001): [web document],
Telehealth.net. Retrieved 01/13 2001, from the World Wide Web:
http://www.telehealth.net/articles/telemed.html.
Mantovani, G. (2001). The psychological construction of the Internet: From
information foraging to social gathering to cultural mediation. CyberPsvchology &
Behavior. 4 01. 47-56.
McCullough, L. (1993). Standard and individualized psychotherapy outcome
measures: A core battery. In N. E. Miller & L. Luborsky & J. P. Barber & J. P. Docherty
(Eds.), Psvchodvnamic treatment research: A handbook for clinical practice (pp. 469-
496). New York: BasisBooks.
McLuhan. M. & Friore, Q. (1967). The medium is the message. London, UK:
Bantam Books.
Meichenbaum, D. (1988). Cognitive-behavior modification workshop. Boston,
MA: Harvard Medical SchoolMassachusetts General Hospital.
Meichenbaum, D. (2000). Treatment of individuals with anger-control problems
and aggressive behaviors: A clinical handbook. Clearwater, FL: Institute Press.
Mendelson, G. A. (1965). Myers-Briggs Type Indicator (MBTI). In O. K. Burros
(Ed ), Mental measurement yearbook. 6. 145-147. Highland Park: NJ: The Gryphon
Press.
Miller, H. (1995). The presentation of self in electronic life: Goffman on the
Internet, [web document]. University of London. Retrieved 02/13 2001, from the World
Wide Web: http://www.ntu.ac.uk/soc/psych/miller/goffman.htm.
Mitchell, D. L. & Murphy, L. J. (1998). Confronting the challenges of therapy
online: A pilot project, [web document]. Retrieved 02/13 2001, from the World Wide
Web: http://www.itch.uvic.ca/papers/ftd/doc.htm.
Moose, R. A. (1981). Group Environment Scale Manual. Palo Alto, CA,
Consulting Psychologist Press.


125
To collaboratively revise, enhance, or focus the set of tasks to accomplish
the goal
Session 2: The facilitator will welcome the participant, ask about the homework
and tasks completed during the past two weeks since the first session, review work
accomplished and work not accomplished. Review the goal and tasks to accomplish that
goal. Discuss progress and obstacles to success. Plan tasks for next two weeks.
Session 3a Face-to-face
Goals: To review work of three sessions and bring about satisfactory closure
Objectives: To continue to develop rapport with the participant
To review independent participant work to date
To process experiences relevant to task and goal since last session
To highlight gains made during therapy
To plan ongoing self help tasks
To bring about satisfactory closure and make referral is necessary.
Session 3a: The facilitator will welcome the participant and work through closure
and termination activities with participant, review progress, homework accomplished and
not, and plan for the participants further self help.
Session 3b Face-to-face
Goals: To evaluate the working alliance, outcome satisfaction and individual differences
of the participants.
Objectives: To continue to develop rapport with the participant
To administer the evaluation instruments
To thank the students for their participation
Session 3b: The facilitator escorts the participant to the computer lab, helps them
log on, make sure the tech is in the help chat room, and give the student the laminated
cards to help with the session. The facilitator will complete the WAI T, his or her
assessment of the therapeutic relationship.
Computer-mediated Sessions are similar with the following exceptions


112
This research indicates that gender and academic learning style affects the
efficacy of counseling. Web clinicians should consider incorporating this information
into suitable screening procedure. There are certainly more critical issues to be included
in screening such as emergency access phone numbers, medication (as an indicator of
seriousness and doctor shopping), however it should be disclosed to males seeking
Internet counseling that research suggests that they might have better results with face-

to-face counseling if that is an option for them. Males should certainly not be excluded
from computer-mediated counseling on the bases of this research.
Academic learning style is likely to be a factor that pre-selects those who seeking
Internet counseling since it was found to be significant in measures of predicted future
use and computer comfort and skill.
Because computer-mediated counseling is often suggested as particularly
applicable for persons with disabilities, follow up research should be designed to
compare keyboarded computer-mediated counseling and voice activated computer-
mediated counseling. Even persons with disabilities who are not currently using voice
activate computer access might be encouraged to do so if research bears out its benefit.
Personal voice activate software has become cheaper than one traditional therapy session
and might be provided by a third party payer in a medical needs situation.
The code of ethics of Certified Rehabilitation Counseling (2002) is being revised
and extended to include Electronic Communication and Emerging Applications,
section I addressing communication and the counseling relationship. The results of this
research indicated that section 12-B h. Inappropriate Use should be expanded to include
some recognition that individual differences may be include in this category as well as


108
indicating that gender is a significant individual difference in predicting face-to-face or
computer-mediated success.
Hypothesis IV. The hypothesis that there is no interaction between ethnicity and efficacy
in either condition could not be disproved in this study design although the relatively
literature on multi cultural counseling suggests that race and ethnicity are important
enough issues to warrant further research with a different design or different process and
outcome measures.
Hypothesis V: The hypothesis that learning style differentially affects efficacy in
counseling in general and between face-to-face and computer-mediated counseling was
supported for prediction of future use of computer-mediated mental health services.
Hypothesis VI: The hypothesis that there is no interaction between personality attitude
(introversion/extraversion) and efficacy in either condition could not be disproved in this
study design although the qualitative evidence in the relevant literature suggests that this
variable is important enough to warrant further research with a different design or
different process and outcome measures
Limitations.
The major limitations of the study were the age and subculture homogeneity of
the participant population, and the acuity of the dependent variables. The participants
were young adults living in a rich, mobile cultural environment of college campuses. The
counseling and guidance resources were multiple and readily available (Counseling
Center, Infirmary, Student Services, Resident Advisors, Activities Advisors, Coaches,
Professors, and such) whereas Internet counseling is seen as most applicable to those with
limited resources and access to mental health care. While this study did provide some
significant results with the population involved, additional research is needed with


138
PARTICIPANTgood question lol
FACILITATORthat symbol 101, what does you mean by it right there?
PARTICIPANTone is an ex, one likes me a heck of a lot more than I
like him, and the other I could see myself with if I could get pass this
"situation"
FACILITATORI see
PARTICIPANTlaughing out loud
FACILITAT0Rok, good
FACILITATORI wasn't sure
FACILITATORok, so one is an ex, but now are you still kinda dating
him?
FACILITAT0Ror is it totally over?
PARTICIPANTno
PARTICIPANThe caused this fear
FACILITATOR>>oooh. So right now you are only dating two
PARTICIPANTyeah. . I guess so
FACiLiTATORwait, wait, wait (now I am the one lanqliing out lead!}
what do you mean I guess so?
PARTICIPANTWell, the ex is.... I don't want him back. I keep him
around for comfort
PARTICIPANTdo you get what I mean
FACILITATORI am getting the ideabut not total just quite yet .
FACILITATORyou still mess around with him? or . you still call
him on the phone . or? {inquisitive look on my face)
PARTICIPANTstraight to the point we mess around when I say
so... comfort! You get me now?
FACILITATORgot it
FACILITATORok, and the other one, he likes you a lot more than you
like him
FACILITATORand then the third . .ok, we got it.
PARTICIPANT:-)
FACILITATORso, you said that your ex made you this way, and that you
think you know why. tell me what happened


11
sessions used in two conditions, face-to-face or computer-mediated sessions. Cognitive
behavioral theory defines and describes salient constructs as cognitive events, cognitive
processes, and cognitive structures (Meichenbaum 1988, Meichenbaum 2000). Cognitive
events are conscious, identifiable or readily retrieved thoughts, images, and
accompanying feelings. These events include internal dialogue, expectations, espoused
beliefs, and appraisals. Cognitive events occur when the persons automatic behavior is
interrupted, when one is uncertain about making a choice or judgment, when one is
troubleshooting, and when one is exercising recall or reconstruction of an event or idea.
Cognitive processes are defined as the way a person processes information.
These processes include information storage, search, retrieval and application. Cognitive
theory suggests that information is received, encoded, stored, retrieved and applied to a
given situation based on the beliefs and values of the individual. That is, not all possible
information, which one encounters, is stored or retrieved. There is a selection process
based on salient beliefs and values. An artist, for example, may store shape, form, color,
light, and texture information extant in the everyday world, which others would miss
entirely. The artist can retrieve that information in another setting because it is relevant
to his or her worldview. At least three of these cognitive processes, confirmatory bias,
mental heuristics, and meta-cognition, are important in psychotherapy. Confirmatory
bias is a process by which the person stores and retrieves information that confirms a
belief or value without questioning the underlying belief. Using this process, the
individual filters out any contrary information or ambiguous information, denying that
individual necessary information in the current situation. Mental heuristics are processes
or templates for making decisions in ambiguous situations. Stereotyping is a common


49
because it is best suited to the participant population, personal growth issue-focus and
alliance development. As such it provides a model appropriate for 3-session, personal
growth focused study conditions.
Cognitive Behavior Therapy
Cognitive Behavior therapy grew out of the work of social learning theorists
including Lewin, Bandura and Lazarus. Prominent researchers in this important area of
theory and therapy include Ellis, Miechenbaum, Beck, Bums, Marks, and Rush.
Miechenbaum (p. 179-198) describes the process of therapy as involving three mental
constructs he calls cognitive events, cognitive processes, and cognitive structures. His
theory links these cognitive constructs to emotion, behavior and logical and natural
consequences of those behaviors. Cognitive events are conscious, identifiable and readily
retrieved thoughts, images and feelings. They include appraisals, expectations,
attributions, self statements, automatic thought and internal dialogue. The person
experiences them as spontaneous, and rarely questions them. These events occur when an
individual is trouble shooting a problem, uncertain about an action or choice, and when a
routine behavior is blocked requiring an alternative or creative solution. Cognitive
processes are the mental processes by which we acquire information, store it in short
term and long term memory, appraise information, filter it, and recall it. Meichenbaum
identifies three cognitive processes that lead to emotional distress confirmatory bias,
mental heuristics and metacognitions. Confirmatory bias is pre conceived notions or
ideas that function as fact. Mental heuristics in the habit of selecting experiences or
information that confirm pre-conceived biases. Meta cognition is the ability, knowledge
or skills to be aware of and control ones own cognitive processes. The process and goal
of cognitive behavior therapy is to educate the client in recognizing his or her cognitive


60
Intuitive Thinking
People using the NT style learning well from long-term independent projects,
experimentation, inventions, and complex problem solving. This style is somewhat
similar to the visualizer and group independent style.
Intuitive Feeling
NF users need cooperative personal relationships and leam best in a friendly
atmosphere. They do not do well in rote, non-democratic environments. They prefer
ideal relationships and excellent interpersonal communication skills somewhat similar to
verbal or auditory learners.
Learning Style Conceptualization Comparison
It should be noted that although there are some similarities between the C I T E,
learning styles and the MBTI learning styles, they are not redundant and each offer a
different perspective on learning. Designed for the classroom, the C.I.T.E. learning style
taps actually educational activities preferences in its items and classifications, while the,
based on the broad Jungian theory of personality and temperament, is more generalized
and perhaps more applicable to life long learning in an educational format and well as in
life in general learning. Therefore, both measures were used as independent measures in
this study.
Measuring Information Processing
Richardson (1977) developed the Verbalizer-Visualizer Questionnaire to access
the extent to which ones thinking processes consists of words or self verbalization versus
pictorial or visual images. It consists of 15 forced choice items adapted from Paivios


117
Outcome Satisfaction Questionnaire (participant form!
NB: This instrument was administered online in the WebCT survey function using an
Software application, Respondus, so the participant view varied from this. They marked
their responses by clicking in the appropriate radio button or text box, not depicted
below.
Question 1 The skills, abilities, and experiences that I learned directly enabled me to
reach the personal growth goal I set for these sessions.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 2 Being able to apply the skills, abilities, and experiences I gained in these
sessions to resolve other stresses and concerns in my life.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 3 The amount of information my facilitator gave me about my particular stress,
concern, or problem.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 4 The amount of information my facilitator gave me about my mental wellness
practice.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 5 The relief from the stress or concern that these sessions provided,
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 6 Overall rating of my facilitator.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 7 Overall rating of my personal growth session
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 8 How would you rate your computer skills (e g., keyboarding, word
processing) and comfort?
Computer guru good user skills adequate user skills novice skills computer phobic


C COMPUTER-MEDIATED SESSION TRANSCRIPT 134
LIST OF REFERENCES 144
BIOGRAPHICAL SKETCH 160
IX


Therapy Plan and Progress Notes
Plan
Participant ID: Counselor ID:
Condition:
Presenting Issues(s):
Participant Strengths:
Resources:
Goal(s):
Ways to reach goal:
Session 2 and 3
Participant ID Facilitator ID
Date:
Condition
Progress Notes (date each entry)


115
The purpose of this doctoral dissertation study is to compare how students feel
about his or her experience of personal growth sessions dealing with common issues
faced by young adults.
What you will be asked to do in the study:
You will be asked to talk about issues that concern you such as adjustment to
college life, relationship with room mate, adjustment to study demands, time
management, stress management and such. You will be asked to participate in three one-
hour sessions with a research assistant. You will be randomly assigned to participate in
these three personal growth sessions in person or via computer. That is, you will either
be assigned to three computer sessions or three face-to-face sessions. You will be
working with one person, a graduate student in counseling for all three sessions. The
graduate counseling student will not be the primary investigator. After the 3rd session
you will be asked to complete five (5) pencil and paper surveys so the last session will
require one hour for your personal discussion and one hour to complete the surveys.
Time required:
4 hours
Risks and benefits:
You will receive three hours of individual personal growth guidance in working
with a personal growth issue of concern to you. You may become distressed and decide
that you need counseling that is available to you at the University Counseling Center.
Compensation:
You may receive extra credit in the course from that you were recruited if the
professor offers it. If this credit is available, it will be no more than 2% of the course
point value. The investigator has no control over the awarding of points. If the professor
offers points, you will receive them whether you complete the study or not.
Confidentiality:
Your identity will be kept confidential to the extent provided by law. Your
information will be assigned a code number. The list connecting your name to this
number will be kept in a locked file in my faculty supervisors office. When this study is
completed and the data have been analyzed, the list will be destroyed. Your name will
not be used in any report. Your professor will be provided with a list of students who
volunteered if you are to receive credit but he/she will not receive any information about
your participation nor whether you completed the study. If you are assigned to the
computer-mediated condition, you will be working on a secure (log-on, password, and
firewall encryptions) web site, however there is a small chance that it could be


31
is that? Physical security is the most crucial place to insure office or Internet privacy and
confidentiality. (Smith 1997) In recent spy scandals, the main issues involved missing
disks, missing laptop computers, and missing hard drives, not Internet or Intranet
security.
Encryption (Smith, 1997) offers the second mode of protecting Internet privacy
but has no application if one uses a cell phone or wireless Internet connection (encryption
is legally defined as a munitions in the USA and 40 other countries). Ironically, it is the
geographically remote who rely on wireless communication. The average user can
connect to the Internet in one of three ways. Dial-up connections use regular telephone
lines. In remote areas, some telephone lines still use analog (rotary, pulse) system and
cannot dial up an Internet Service Provider (ISP). Television cables offer another way to
connect to the Internet, but cable television is likewise not economically feasible for the
companies in remote areas and therefore not available to one of the most under served
populations. Dish satellite is available in remote areas but because it is wireless, it cannot
be legally encrypted. Most high-speed Internet connections rely on microwave towers
and as a result are wireless even when offered by the local telephone carriers. Cable
high-speed Internet connections are probably the only DSL connections that use physical
wire. Internet security is a matter of therapist knowledge and proper application of both
hard ware and software solutions (Smith, 1997). T-4 lines are the most secure, most
expensive, and least available to the average therapist. Furthermore, even if the therapist
has a secure high-speed connection, the actual communication between a therapist and
client can only proceed at the rate of the slower system.


151
Hegarty, M. P. (1997). Promoting counseling in the global village, [web
document]. Counseling Today Retrieved 06/20 2001, from the World Wide Web:
http://www.counseling.org/members/ctonline/archives/iicc htm.
Holmes, L. (2001). Mental Health Resources with Leonard Holmes, Ph, D,: Your
guide to one of over 700 sites, [web document]. About: The Human Internet. Retrieved
05/11 2001 form the World Wide Web,
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HON. (1995). HON Code of Conduct (HONcode! for medical and health Web
sites [web document]. Health on the Net Foundation. Retrieved 07/08 2001, from the
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Horvath, A. O. & Gaston, L. (1993). The therapeutic alliance and its measures. In
N. E. Miller, L. Luborsky, J. P. Barber & J. P. Docherty (Eds ). Psvchodvnamic treatment
research: A handbook for clinical practice (pp. 247-273). New York, NY: BasicBooks.
Horvath, A. O. & Greenberg, L. (1986). The development of the working alliance
inventory. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 529-556). New York, NY: Guilford Press.
Horvath, A. O. & Luborsky, L. (1993). The role of the therapeutic alliance in
psychotherapy. Journal of Consulting and Clinical Psychology, 4. 361-573.
Horvath, A. O & Mars, R. W. (1991). The development and decay of the working
alliance during time-limited counselling. Canadian Journal of Counselling. 24. 240-259.
Horvath, A. O & Symonds, B. D. (1991). Relation between working alliance and
outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology. 38, 129-
149.
International Society for Mental Health Online (2000). Suggested principles for
the online provision of mental health services, [web document], ISMHO, Retrieved 07/08
2001, from the World Wide Web: http://www.ismho.org/suggestions.html.
Jones, E. (1996a). California governor signs landmark reimbursement bill, [web
document]. Telemedicine, 9961101 Retrieved 06/08 2001, from the World Wide Web:
http ://www.telemedmag. com/db_area/archives/l 996/961101 n2. html.
Jones, E. (1996b). Minnesota okays reimbursement for home based telemedicine,
[web document]. Telemedicine, 960801 Retrieved 06/08 2001, from the World Wide
Web: http://www.telemedmag.com/db_area/archives/1996/960801 n32.html.
Jackson, M. & Davidson, C. T. (1996). The web we weave: Using the Internet for
counseling research. Part II. [web document]. Counseling Today Retrieved 06/20 2001,


10
that identifies six components of social presence, a prerequisite to interpersonal
relationship on the Internet and, therefore, a prerequisite to Internet counseling social
warmness, realism, transportation you are there, we are there, perceptual and
psychological immersion, social actor within the medium, and medium as social actor
(Lombard 1997). Almost all counseling theories emphasize the importance of the
interpersonal relationship between the counselor and the clients, although they may vary
in the manner in which they deal with the helping relationship, transference, counter
transference, or working alliance. It is reasonable then to infer that social presence is a
key concept for the development and evaluation of Internet counseling. It should be
noted that several projects have attempted to create computer-as-counselor (Wizenbaum
1966, Maes 1995, Ookita, 2001). However, this study examines the human counselor
client interaction with computer as communication mediator. Computer-mediated
communications is not, in and of itself, psychotherapy, no matter how personal,
rewarding, helpful and satisfying it may be. Hampton and Houser emphasized that the
Internet is a tool and it has no more inherent ability to cause harm than a telephone. Like
other tools, if we use it properly, it will be helpful and beneficial. However, if we misuse
it, the consequences will be detrimental (Hampton 2000). A century of research and
application have demonstrated that psychotherapy is a particular form of communication
supported by heuristic theory, discrete techniques, and demonstrable outcome results.
Now research must do the same for computer-mediated communication so that Internet
counseling will be helpful and beneficial rather than detrimental.
This study was designed to contribute to that needed body of research. To do so,
the study compared brief cognitive behavioral theory applied in personal growth


104
Presence It was cool to be able to just log online to talk, it was easily
accessible, but instant messages sometimes lack tone of voice that can
make it more difficult to understand the subtleties or conversation, plus,
in some ways the annonymity of doing it over the computer was nice, i
could cry or whatever without feeling watched and i could talk from the
privacy of my own home that was both good and bad, good cause it was a
comfortable place, bad because afterwards i couldnt leave some ..
Trustworthiness I just really realized how helpful it is to talk to
someone who is totally objective and knows nothing, or has made no
judgments, about you. It was really cool to have facilitator because he
went through some of the problems that I am going through right now, and
he was able to disclose his experience with me and make me feel better
about my decisions
Intimacy I feel that using the computer was nice, it gave you a way to
communicate, without feeling self conscious about what was being said
Other students were less happy with their computer-mediated experience.
Presence I think this is great to look at. However, I feel that the
computer is an inefficient way to communicate thoughts to another person
due to the ambiguous nature of the internet
Having the counseling sessions over the computer made it seem as if we
were wasting some of our time. There was sometimes a lag in the chat
room, and I would often sit waiting to see what the facilitator had to say. I
feel that the sessions might have been more productive in person. Further,
I did not feel very comfortable having to type my feelings on the
computer. It was a bit strange having to type I am smiling I am
laughing, ect
I did not like the internet sessions that much because I tended to forget to
sign on line. If I had an appointment to go to I feel that I would remember
better. Also, you could not see facial expressions or how the other person
was feeling at the time. This is hard when you are
There were times that I didnt know how to put what I felt into words. I
feel that if I had been in an actual office with a therapist they may have
been able to lead me through my feelings and putting them into words. I
think that when it comes down to it a person needs the one on one that an
in office session gives.
Trustworthiness The computer is not always reliable and to think that
therapy will be given through the internet is depressing


32
The issues for email, chat, and bulletin board security include authentication, non
repudiation, public key distribution, and mailing list handling (Smith 1997, p. 287-296).
Authentication asks who wrote the message did the therapist write the message the
client receives, did the client write the message the therapist received. Non-repudiation is
important in legal matters, commonly business contracts but, for the therapist and client
in potential lawsuits divorce, custody, criminal, and malpractice. Public keys are
passwords and other encryption devices use to allow discretionary access to information.
Mailing list, (e g., listserv, USELIST) are difficult to encrypt because the decryption must
be specific for each receiver.
Cryptography and secret codes has a long history in government, intelligence and
military use but equally if not more importantly in business and commerce. Modem
cryptography has been spurred by the business and commercial needs of the Internet and
by major advances in modem mathematics that provides the means to develop nearly
indecipherable code algorithms. The therapeutic community is rightly concerned about
privacy and confidentiality. However, hacking or breaking into a properly secured
computer system, is actually very difficult, rare and targets valuable and marketable sites.
With this caveat, the therapist is wise to encrypt his or her site for the protection of the
therapist/client communication and use a third party secure payment company, which
specializes in the coding/decoding in monetary transactions. This protects both the
therapist and the client from external credit card fraud, exploitation, and subterfuge. It is
the most complex, expensive and restrictive form of encoding. Companies exist to
handle financial transactions because the ordinary transactions of many businesses are
not worth the time and trouble required to intercept or forge them. It is a much better


77
help desk for students who have any difficulty accessing or using the system and
participants were notified of these services.
Midway through the study, the University moved WebCT to an authenticated server
that required identification at log on. However, the university maintained the original
server for studies such as this that require anonymous or coded logon. This did not
negatively affect the study in any way because site appearance remained the same to the
facilitators and because the participants had never seen the other system. When
participants navigated to the WebCT home page, they found this among other studies
listed individually with a link to the older server (e g. Participants in the Groble
dissertation study click here). The one possible confound was that the new server
relieved the lag time problem encountered in the spring term when the old server was
overloaded. Facilitators either did not notice or did not mention any difference. The lag
was inconsistent in the spring depending on the time of day of appointments.. The lag
occurred when the system was experiencing heavy use throughout the university. The
facilitators may have adjusted their scheduling to minimize this problem.
Data Collection Procedures
The principal researcher established a dedicated, password secured web site with
a text-talk (chat room) application for use by facilitators who conducted the personal
growth sessions and data collection. Recruitment was conducted in the source
classrooms during regularly scheduled class with the instructors permission to discuss
the study, explain the participants rights to withdraw without harm, obtained informed
consent and contact information. The principal researcher did not access to the web site
once the study begins and each assistant was instructed how to secure his or her


119
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 4 The amount of information I gave this participant about his/her particular
stress, concern or problem.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 5 The amount of information I gave this participant about mental wellness
practice.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 6 The relief from the stress or concern that these sessions provided this
participant.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 7 Overall rating estimate of this participants reaction to me.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 8 Overall rating estimate this participants growth sessions
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied


135
FACILITATORWas it hard to get in?
PARTICIPANTyes. well I did not click on the dissertation link
PARTICIPANTat first
FACILITATORoh, no, that can get real messy
FACILITATOREverything works fine until it doesn't
PARTICIPANTlol
FACILITATORHow are you doing?
PARTICIPANTfine
PARTICIPANTand u?
FACILITATORgood. I have had a crazy morning, I work part time in
Shands psychiatry, and I showed up for 2:30 for the group, but it was at
1:00!
FACILITATORSo I missed it all ¡lUp) !
PARTICIPANTSorry to hear that... I hate those kind of days
FACILITATORyeah
FACILITATORwhat about yours? Did you have class today?
PARTICIPANTyes, I enjoy my classes they are pretty easy going right
now
FACILITATORhave you taken any Internet?
PARTICIPANTnever
FACILITATORso you are fresh! Wringing, hang?) What we
could do to you!
facilitator(ironic, joking of. iSeuxse)
PARTICIPANTlol
FACILITATORSo, I want to explain a little bit about what this is
going to be like. Is that cool?
PARTI Cl PANTyes
FACILITATORI will spend about 5-10 minutes explaining a couple
things, then we can talk about the "meat", and then in the end we will
try to come up with a "plan" or homework for you to do until the next
time I see you
PARTICIPANTokay


UNIVERSITY OF FLORIDA
3 1262 08557 2476


146
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2001, from the World Wide Web: http://www.cognitivtherapy.com/learning.html.


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING
By
Martha Lana Bogardus Groble
December 2002
Chair: James Archer Jr.
Department: Counselor Education
This study examined the process and outcome efficacy of Internet counseling by
comparing it to traditional face-to-face counseling in an experimental environment. We
recruited 123 undergraduates from fourteen classes in two institutions of higher
education. Students volunteered to participate in three personal growth sessions and
complete five surveys. Ten graduate students were trained to conduct brief cognitive
behavior therapy in personal growth sessions within the research protocol. Facilitators
were trained to use the chat room and survey functions of the Universitys secure remote
classroom system WebCT.
Participants were randomly assigned to the face-to-face or computer-mediated
condition. Facilitators conducted an equal number of sets in each condition but each
participant was seen in only one of the two conditions. The demographic survey was
conducted in the classroom during recruitment while the other four surveys were
completed after the last of the three personal growth sessions in the WebCT survey site,
whether the participant had been assigned to the face-to-face or computer-mediated
condition. Facilitators completed two surveys after each set of sessions.
x


156
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217-229.
Short, J., Williams, E. & Christie, B. (1996). The social psychology of
telecommunications. London: Wiley.


9
ofPsychnet.com sell mental health related domain and the tools to develop them at
http://www.psvchnet.com.
Concerned professionals began researching the Internet services, even before the
Internet became available to the public in 1994 (Colon 1994). Professional organizations
have been debating salient issues (Holmes 1997). The federal government has passed a
telehealth bill (U S. Congress 1997, HCFA, 1996, HCFA, 1999). In 1997 the state of
California enacted the first state law restricting California therapists to in-state Internet
clients (Maheu 2001). The American Counseling Association researched current practice
in distance learning related to mental health and cyber counseling. A major
recommendation from that study was the need for research in the area of cyber
counseling (Brown & Walz 2000). Cyber counseling research must build the theoretical
foundation and constructs of Internet communication and of mental health counseling.
Theoretical Framework
The theoretic framework for this study consists of the constructs of social
presence, (Lombard 1997, Reid, 1994), trustworthiness (Edwards 2000) and intimacy
(Robson 1998) in cyberspace, counseling in cyberspace, person centered alliance building
skills, brief counseling, learning styles, and personality traits. Psychotherapy is a human
relationship that heals (Suler 1999). For a relationship to develop both participants must
be involved in a personal, dynamic manner. Earliest theories of the Internet as simply an
impersonal source of information were quickly replaced by the information foraging
cognitive model (Priolli 1999), the sociological gathering and communicating model
(Sproull 1997) and the anthropological expanding human experience. understanding
artifacts, and culture model (Mantovani 2001) to better reflect the evolution of Internet
use and the experience of Internet users. The Social Presence Theory is a micro theory


APPENDIX B
FACILITATOR TRAINING MANUAL
Table of Contents
1. Logistics
2. Procedure section of dissertation proposal with protocol for each session
3. Record forms
4. WebCT access information with copy of each screen from http to chat room
5. Brief Cognitive Behavior therapy material from Meichenbaum
6. Computer Counseling Technique (articles listed in required reading)
7. College Student Personal Growth Issues (articles listed in required reading)
Front pocket
Treatment plan forms
Progress notes forms
Back pocket
Facilitator checklist
Contacts: Martye Groble Martve@att.net 19041 387-2617
Loren Groble Groble Robert@hotmail.com (352) 335-0118
(your local all-purpose helper)
James Archer Jr. Jarcher@coe.ufl.edu
(dissertation committee chairman)
120


66
To measure the presence and relative weight of these constructs research teams at
the University of Pennsylvania developed the Penn Helping Scale (Alexander & Luborsky
1986); at Vanderbilt, the Psychotherapy Process Scale and the Negative Indicators Scale
(Suh, Strupp, & O'Malley 1986); and at Simon Fraser University, the Working Alliance
Inventory. (Horvath & Greenberg 1986). These projects all based their work on the
Bordins (1976) three-factor operational decimation of the helping, therapeutic, working
alliance that consisted of interpersonal bond between the client and therapist. This is
transference/counter transference without a pathological implication. Bordin further
suggested the need for agreement between the client and therapist as to the goal of therapy
and agreement as to the tasks required to accomplish this goal. From 1976, Bordin
maintained that, to be effective, the therapeutic relationship must be collaborative, not
hierarchical.
Measuring Therapy Outcome
Outcome evaluation has evolved from early opinions of the therapists, to complex
testing using instruments including the MMPI (McCullough 1993), to semantic
differential studies designed to cover all possible theories available and obfuscate the
purpose to the measure to avoid contamination (Stiles 1980), to market driven consumer
satisfaction surveys (Patterson & Leach 1987). Therapist opinion may be highly accurate
or may be self serving in any given situation. A structured form of therapist opinion has
been developed and normed over four decades and five versions of the Diagnostic and
Statistical Manual. (DSM). The Global Assessment of Functioning (GAF) (APA 1994) is
the most widely used outcome measure because it is the Axis 5 measure, required as part
of the five-axis mental health diagnostic report. Its use has been increased by the demand
of most HMOs and PPOs for use of the five-axis system.


137
FACILITATORok, whew! After all that, any q's?
PARTICIPANTok
PARTICIPANTno
FACILITATORthen .
FACILITATORtell me what we are here to tak about
FACILITATORtalk Coops U
PARTICIPANTwhat area are you mostly concerned
FACILITATORwhat do you mean? What area am I mostly concerned with?
let me turn the question around what area are you mostly concerned
with?
PARTICIPANTpersonal relationship
PARTICIPANTrelationships
FACILITATORwith a friend? boyfriend? tell me more
FACILITATOR(ley, by the way, if I interrupt, dont worry)(just keep
going)(smile)
PARTICIPANTboyfriend, I have this fear of commitment and I know
where it came from but I just don't know how to get rid of it. I always
question behind a guys motives for telling me his feelings even if we
are dating (like movie and dinner)
FACILITATORare you dating someone now?
PARTICIPANTseveral
PARTICIPANT! am scared to limit myself to one person
FAC1LITAT0R|||§!!
PARTICIPANTlol
FACILITATORoh, I see, so you think that's why you are dating several
at a time
PARTI Cl PANTyes
FACILITATORhow many are we talking here?
PARTICIPANTthree
PARTICIPANTthey are nice guys\
FACILITATORso, you are dating three guys because you are afraid to
limit yourself to just one. Before we go farther, let me ask do you
like all of them?


130
WebCT Samples Screens
Checking your participants survey status. With TA level WEBCT access you can
check the status of your participants and know who has completed their surveys and who
has not. You must do this one survey at a time. To get to this screen click on the
opinions icon on the first page of the study site. You will see something like screen shot
1 below. You cannot bring up the surveys here because as you can see they are not hot
links. However you can see two hot links blue or purple with underlines. The date
and availability are also blue but I think that is just to make them easy to find. The live
links are the ones with underlines. By clicking on a submissions link you will see a
screen like the one captured in screen shot 2 below. The detail link is illustrated in
screen shot 3. On the right you have some options (second set) to help you find what
you want without flipping through all the next and previous buttons.
Screen Shot 1 First page of survey section
KWMWW
mm
500
Quit rus Survey Mntg#m*nt
t-c pjt iiM >\vj jf onrgj OTEItFT SXILCSE *5 her au.". \Vtt>CT If yv>v src usy<$ tire lutcrrtet EijaImv.' bro*r*e.r. vat
vd change to tfi/. IE triw.*/ AC*L ->y 'WvCT. h.wmr ¡roa cao Troorttoe E y.vu Ur cookie**. IIm rwr m rhe vVoerot ehoi f-oas ttv meareh soj.-iy (kewew/ Jf thiji 4r.ee o.'.e W.A try tfex ottow ^eoerot ehw r.o*v> If you huer. orry .yoxanoo?. jr.fohiAM, .'.t
< *> to- U*- );oo> pav, toe cisck t o :li* Ewujcm <.Vowf f>ttMco :t on wvkh iVoro jrj #o to tJie >u eooau eedwn TbjooSc youfcx vo>x
piNtK^-ettO]) o) An peojet*
Ct*- Ttote
'Dtaarcefetfos* <
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APPENDIX A
FORMS AND INSTRUMENTS
Research Participant Information Sheet
This information is strictly confidential and will be used only for purposes of this study
including contacting the participant to schedule sessions, allow reporting to instructors
for purposes of class credit where it is offered, demographics of study, and such.
Date:
Name:
E-mail Address:
Local Phone number:
Age:
Level freshman
Major:
Instructor: Class:
Best day of week to schedule study sessions: M TU W TH F
Best time of day morning afternoon evening
Disability accommodations needed (specify) Contact Information Sheet with
demographic information
Informed Consent
Project Title: Process and Outcome efficacy of 21st Century Counseling Techniques
Please read this consent document carefully before you decide to participate in this
study
Purpose of the research study:
Gender: Race(s):
sophomore junior senior
114


xml version 1.0 encoding UTF-8
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INGEST IEID EKVTF3ECG_IPOD86 INGEST_TIME 2014-10-09T22:03:38Z PACKAGE AA00025816_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES


64
introverts are a minority group comprising only 25-30% of the total population, (p. 8).
While intriguing, this may be skewed by the obvious fact that the mailing lists are
presumably drawing from a world population rather than a US population. Livingood
himself writes from Australia. This perception may also reflect the observation that the
people who first had access to the Internet and continue to have predominate access to the
Internet are engineers and scientists who make up that 25%-30% of American introverts
(Myers 1982). The use of the introversion/extroversion scale in this study is significant
because the study population is United States citizens or international students choosing
to study in the United States. The participants were recruited from the College of
Education rather than engineering or science.
Counseling Process and Outcome
During the first half of the 20th century, researchers primarily focused on
understanding the psychological processes that affected the well being of the population.
This research generated the great theories of personality and the applied therapies have
helped people enjoy a better quality of life for three generations. In the second half of the
century, researchers began to examine how the therapies produced the results that were
anecdotally abundant. They examined what factors, conditions and environments that
increased or decreased the efficacy of therapies. Financial accountability in government
health care service has driven research in outcome efficacy and consumer satisfaction for
the past two decades. In the mental health field, this research has taken two primary
directions, efficacy of the counseling process, the helping relationship, (Gaston 1991,
Greenson 1965, Hartley & Strupp 1983, Alexander & Luborsky 1986, Klee, Abeles, &
Muller 1990, Kobotovic & Tracey 1990, Horvath & Symonds 1991, Horvath, Gaston &
Luborsky 1993, Horvath & Luborsky 1993) and efficacy of the over all experience,


26
emotion and embodiment are incorporated in text-based communications. Letters,
missives and discourses were the major form of communication from the invention of
writing at least as early as 5,000 B.C.E. until the invention of the telephone, telegraph,
and radio in the last 19th century (Bell 1867, Bell 1895, and Marconi 1900). The most
common and wide spread convention for expressing emotion on the Internet is the smiley
or alternately the emoticon. Early on, the need to encode and covey feelings was
recognized in the computer chat space. Carnegie Mellon Principal Research Scientist,
Scott Fahlman, (1995) admits
Yes, I am the one who first suggested the use of the :-)
and :-(glyphs in E-mail and bboard posts sometime around
1981. People were making sarcastic comments in posts,
others were taking them more seriously than they were
intended (no body language on the net), and silly arguments
were breaking out. So I suggested on one of the CMU
bboards that people explicitly label comments not meant to
be serious with a :-) glyph. Very quickly, this idea spread
all around the world and others started creating clever
variations on the theme. The awful term emoticons is
much more recent.
These glyphs (see ZBoray 1997) are an important part of routine Internet
socializing but are inadequate for expressing the range of non-verbal cues necessary in
counseling. Other rules of appropriate behavior (netiquette) on the Internet also evolved
to smooth social interactions (Rinadli 1998) and should be observed by the cyber
counselor but like glyphs, netiquette is not sufficient for the needs of the counseling
relationship. The introduction and development of glyphs and netiquette demonstrate
that the need and convention was recognized early in the development of text-based
communications.


47
true than in the Internet environment. PayPal.com acquired by Amazon.com in July 2002
offers some of the same financial recourse as services continue to evolve in the credit
card industry as e-commerce grows. Unless the URL begins with https (hypertext
transfer protocol secured), the site is not secure. Unless there is a small padlock icon on
the status bar of Internet Explorer or Netscape, the site is not secure. Again, many
consumers, especially in a time of stress or crises precipitating contact with a counselor,
may not be aware of these Internet conventions. To avoid the expense of a secured site,
many small merchants ask that credit card numbers be emailed to the site. Email can be
secure but again, if it is, there is evidence of that security that clients are unlike to know
or consider in a time of distress. Does Internet counseling provide privacy and
confidentiality both in personal information and financial information? It can, but many
sites do not.
There is often legitimate concern in physical counseling rooms about thin walls,
crowded waiting rooms, and non-counseling staff access to chart notes. There are,
however, analogous problems in a cyber counseling room the clients own family or co
workers may have access to the screen as the client talks with the counselor or to the
records in the computer. A spouse seeking a contested divorce, a vindictive co-worker
and other persons with agendas harmful to the client may be able to print off logs of the
sessions, emails, or bulletin board postings. Clients, computer end users, may or may not
be aware of what is recorded in the computer program itself. A client can conscientiously
protect his or her email correspondences, and yet never know that the chat session is
automatically being saved by the computer software. The clients own associates may
have more access to the very information that the client needs to have secure from others.


REVIEW OF LITERATURE
The relevant scholarly literature is reviewed in this chapter. Topics to be reviewed
are research; Internet computer counseling concepts; Cognitive counseling theories;
personality traits; temperament learning style; academic learning style, and counseling
outcome and process theory. The exiting Internet research, which is primarily qualitative
and heuristic, addressed the social and cultural dimension of Internet transaction and the
construct of social presence on the Internet, a prerequisite to counseling. The advantages
and concerns about Internet counseling as discussed by the mental health professional
organizations and activists, and current applications of counseling on the Internet. While
outcome efficacy of Internet counseling is a concern in all theoretical approaches, for the
purposes of this study, the theory used is brief cognitive behavior therapy. Research
regarding basic precepts of cognitive behavioral therapy, basic precepts of brief therapy
and the construct of working alliance are reviewed. Relevant research about personality
traits, theory and application of learning styles are discussed as related to independent
variables in this study. The theory and instrumentation for evaluating the independent
(personality type and information processing style) and dependent (working alliance and
outcome) variables are presented. This chapter concludes with a discussion of the
contribution of the existing research to the formulation of the present study.
Internet Counseling Basic Constructs
To counsel in cyberspace, one must first assess the constructs and theories
defining human relations in cyberspace. Counseling is a human interaction, which is a
21


57
interest to the present research, academic oriented learning styles and temperament based
learning styles. Academic learning style theory addresses specific skills and tasks
generally incorporated into formal pedagogy. Temperament based learning styles affect
how the individual learns formally or informally by his or her inborn nature and traits.
Academic Learning Styles
Of the researched styles, verbal, visual, kinesthetic, group, individual, oral
expressive, and written expressive (Babich, Burdine, Albright & Randol 1976), the most
consistently identifiable and validated styles have been visual and verbal (Lazarus 1964,
Richardson 1969, Richardson 1977, Delaney 1978, Dyckman & Cowan 1978, Akins,
Hollandsworth, & O'Connell 1982, Akins, Hollandsworth, & Alcorn 1983, Pavio &
Harshman 1983, Maclnnis & Price 1987).
Richardson (1969) cites a late 19th century researcher, Lay, who illustrated his
concept of the misunderstanding among people as being a result of learned or innate
preference for verbal processing or visual processing with the historical animosity
between Greek philosophers Socrates who heard the voice of his daemon and
Protagoras who thinking and debating relied upon visual/kinesthetic processes.
Richardson quotes Lay as saying if one is auditory-linguistic he should never enter into
an argument with a motor-linguistic person, as on all topics except the most concrete
facts, either will inevitable fail, completely, to understand the other (p. 83). The
preference many mathematics students have for either word problems or equations is a
relatively common example of the encoding, processing and retrieval impact of verbal
processing or visual/symbolic processing, respectively. Lazarus (1964) deemed visual
processing to be a crucial factor in systemic desensitization therapy. Now, nearly 40
years later, the question must be asked if the ability to visualize a virtual counseling


15
Purpose of the Study
The purpose of this study was to compare and contrast the development of
working alliance (Horvath 1993, Horvath & Greenberg 1986, Horvath & Mars 1991,
Horvath & Symond 1991), and outcome satisfaction with traditional face-to-face brief
group counseling and with computer-mediated brief group counseling. The effects of
learning style (Babich 1976) and personality traits were analyzed to determine if potential
differential efficacy of face-to-face or computer-mediated counseling could be predicted.
The study will examine which, if any, specific learning style and personality traits are
predictive of success in one modality or the other.
Need for the Study
Few studies exist to guide psychotherapists who decide to move all or part of their
practice to the Internet. Most of these studies are surveys and other qualitative studies as
is appropriate for developing heuristic for a new area of inquiry (Barak 1999, Colon
1994, Dunaway 2000, Fink 1999, Harris-Bowsbey 2000, Stubbs 2000). Virtual Reality
(VR), the high end of Internet technology is being studied with statistical rigor in the
treatment of phobias (North 1994, Rothbaum 1997), cardiac illness in children (Bers
1997), and chronic pain at a bum clinic (Patterson & Hoffman 2000). Ethics working
papers and guidelines exists to structure Internet psychotherapy (NBCC 1997, ACA
1999, AMIA 1998, APA 1997, Brown & Walz 2000, Holmes 1997, NBCC 2000, CRCC
2001) and there is no dearth of technology and technical assistance to develop and market
Internet therapy. There is however, a critical need for empirical research to analyze
typical Internet therapy after almost a decade of development.
The primary therapeutic use of the Internet appears to be Internet support groups
(King 1998). Because of this widespread use, the American Psychological Association


51
thinking or irrational beliefs. His ABC model has grown alphabetically over time but still
focuses on an Activating event, some event at work, home, or interpersonally that triggers
the emotional crises or Consequences. The client experiences the Consequences with or
without being aware to the triggering event and generally without being aware to the
irrational, rigid belief that connects a triggering event to the emotional or behavioral
consequence. In REBT, the irrational Belief is Disputed using cognitive skills introduced
by the therapist but practiced in homework by the client. The outcome is effective and
efficient responses to would be Activating events. Ellis identified eleven irrational
beliefs that cause the gamut of emotional problems.
Some of the websites established by founding CBT therapists are located at:
Aaron Beck, M.D. http://www.beckinstitute.org; David Burns, Ph D. -
http://feelinggood.com ; Albert Ellis, M.D. Http://www.rebt.org ; Isaac Marks, M.D., -
http://www.thisiswiltshire.co.uk/; Donald Meichenbaum Ph D. -
http://www.arts.uwaterloo.ca ; and A. John Rush, M.D.
http://www3.utsouthwestem.edu/psvchiatrv/facbios/rush.htm/
Brief Cognitive Behavior Therapy
Ellis (1996), Beck (1979) Bums and Meichenbaum (2000) have each researched
and developed brief cognitive behavior therapy protocol some of which are as brief as
one session maximum benefit. In a World Counseling Network forum Ellis (1998)
describes REBT as designed originally because psychoanalysis and most other forms of
therapy were very long winded. So I tried to devise a system that would understand the
core beliefs, the core irrational beliefs of the clients very quickly and help them to get to
work to dispute them and debate them in a short period of time. So in a sense REBT was
on to the few therapies designed to be brief (p.2). In reply to a question about efficacy


I certify that I have read this study and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
dissertation for the degree of Doctor of Philosophy.
I certify that I have read this study and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
dissertation for the degree of Doctor of Philosophy.
M. Harry Daniei^t
Professor of Counselor Education
I certify that I have read this study and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
dissertation for the degree of Doctor of Philosophy.
Professor of Rehabilitation Counseling
I certify that I have read this study and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
dissertation for the degree of Doctor of Philosophy.
M. David Miller
Professor of Educational Psychology


CHAPTER 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
The purpose of this study was to explore the efficacy of Internet counseling and
the impact of individual differences on that efficacy. This chapter summarizes the study,
discusses the results and offers conclusions, and recommendations for further study.
Summary of the Study
This study was conducted in Florida with undergraduate student participants and
graduate student facilitators from a university and a community college in the same
municipality. One hundred and twenty one students volunteered to participant in three
personal growth sessions and completed the sessions and five surveys (demographics,
learning style, personality traits, working alliance, and outcome satisfaction). They were
randomly assigned to either the face-to-face or the computer-mediated condition. The ten
counseling graduate student facilitators were trained and provided with a detailed
procedure manual and report forms. Each facilitator worked with an equal number of
students in each condition. Analyses of Variance were conducted using individual
differences gender, ethnicity, learning style, and personality traits as the independent
variables. Follow up tests were conducted to analyze variables that demonstrated a
significant main effect or interactions.
Conclusions
Six hypotheses were examined and the results will be discussed individually.
Hypothesis I.. The null hypothesis that there is no difference between face-to-face and
106


139
PARTICIPANTwell. . .
PARTI Cl PANTwe were together for a year and a half
PARTICIPANTand I told him eight months into the relationship that I
loved him
FACILITATORand you meant it, or you just told him?
PARTICIPANT! meant it... he waited longer to say the same becuz he
said that he did not take that word lightly
PARTICIPANT! meant it
FACILITATORand, I am guessing something happened, right?
PARTICIPANTyes
PARTICIPANTwe started going through problems, he was taker and I was
always the giver.
FACILITATORdid he ever return the words?
PARTICIPANT! felt like he did not appreciate me.yes, he said he
loved me
FACILITATORand when it broke off, who broke it off, you? I am
guessing, if you still keep him around?
PARTICIPANTAfter about three months of going through arguements off
and on
PARTICIPANT! did broke it off because he told me one night during a
conversation that he did not love me nor did he know if he meant it the
first time. We were just having a conversation
FACILITATORoh man
PARTICIPANTbreak it off
FACILITATORit hurt really bad, right?
PARTICIPANTsomething in me change from that night. I never cried so
hard in my life.
PARTICIPANTit still hurts
FACILITATORyeah
PARTICIPANT! don't want that feeling ever again.
FACILITATORdid you all break it off then, or did you kinda hang on
for a while?
PARTICIPANT! returned the favor
FACILITATORyou mean you told him the same thing?


92
score range was from seven to twenty-seven in the face-to-face condition (M =12.64, SD
= 4.88) and from seven to twenty-four in the computer-mediated condition (M = 13.76,
SD = 4.29). This does not mean that the participants were dissatisfied with their
experience but that the measure of satisfaction did not detect any independent variables
that influenced satisfaction. In other words, the participants were equally satisfied in
either experimental condition and regardless of individual differences.
Working Alliance Inventory Total (Client)
The Working Alliance Inventory provided four measures, a total rating, and three
subscale scores. The subscales measured bond, similar to rapport, agreement on goal to
be achieved in counseling, and agreement of task(s) to be developed to accomplish the
agreed upon goal of this episode of brief counseling. There were no significant main
effects or interactions for the dependent variable WAI (c) total score (Table 8).
Table 8. Source table for dependent variable WAI (c) Total score
Sources of Variance
Type HI Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
9574.904
19
503.942
.947.528
Intercept
216085.736
1216085.736
406.031.000
Condition
521.780
1
521.780
.980.324
Gender
153.238
1
153.238
.288.593
Ethnicity
817.424
2
408.712
.768.467
Academic Learning Style
1251.056
2
625.528
1.175.313
Introversion/ Extraversin
109.434
1
109.434
.206.651
Temperament Learning Style
1433.145
3
477.715
.898.445
Condition by Gender
817.339
1
817.339
1.536.218
Condition by Ethnicity
833.397
2
416.698
.783.460
Condition by Academic Learning Style
36.584
2
18.292
.034.966
Condition by Introversion/ Extraversin
206.308
1
206.308
.388.535
Condition by Temperament Learning Style
2112.052
3
704.017
1.323.271
Error
54618.875
104
525.181
Total
1346441.000
122
Corrected Total
63858.369
121
a R Squared = 126 (Adjusted R Squared = -.026)


161
a Ph D. in mental health counseling (specializing in vocational rehabilitation counseling)
in the fall of 2002. She is a certified rehabilitation counselor and a certified career
assessment associate. She is an adjunct instructor at the University of North Florida in
the department of Rehabilitation Counseling and she is the primary care giver for her
husbands neptuagenarian parents who live with them.
As a mathematics major, Dr. Bogardus began learning computer programming in
1967. Her knowledge and skills grew as the computer world became accessible to
individuals. She designed the computer lab at St. Marks Episcopal Day School in 1993
and focused her graduate research in the area of computers and counseling.
She is an avid genealogist, proficient in the use of computer data bases to research
lineages. She records her findings in traditional scholarly format and in personal
photographic journals that she shares over the Internet in prominent genealogy sites, and
on her family website. She enjoys textiles including sewing and quilting with a
computerized sewing machine, and hand stitching needlepoint, petit point, crewel, and
embroidery. She relaxes by reading fantasy literature (brain candy) and enjoys fantasy
role playing gaming. When away from her computers, books and 30-sided dice, she
hikes, swims, canoes, rafts, sails, and backpacks on four continents with plans to explore
two more continents. Although she and her family camp extensively and world wide as a
family or with Scouts and friends, her favorite campsite has always been Holiday Inn
poolside.


75
this form of communication and counseling available to them. There is also concern that
as women are thought to be more relational in their orientation while men are more
analytical, computer-mediated counseling may disadvantage female clients.
Learning styles that favor visual learning, written expressiveness and/or
individual work may be more adaptive to Internet counseling while verbal learning, oral
expressiveness and/or group work may be disadvantaged in a computer-mediated
environment.
Personality type, likewise, may predispose some clients to more comfort and
effectiveness using computer-mediated counseling and disadvantage others. The
personality trait introversion/extroversion was an independent variable to determine if
introversion is predictive of great outcome satisfactions than extroversion.
Population
The population was a southern university undergraduate population and from a
community college in the same locale, with an age median of 20. This population is
thought to be representative of computer users who use computers for social as well as
technical purposes, have grown up in a technological age, and are of the age and social
class most representative of computer users. Undergraduates volunteered for the study
after hearing a presentation in their classroom, completing a contact sheet with
demographic information, and signing an informed consent. They were provided with a
duplicate of the informed consent form and were randomly assigned to personal growth
sessions in either a face-to-face or computer-mediated counseling condition. Participants
were enrolled in stress management, substance abuse, or interpersonal skill classes in the
department of counsel education or in the student development classes at the community
college. Students (N = 123; M = 29; F = 94) were contacted by their facilitator and


8
website. She learned that the 13 respondents served 445 clients in 1995, 947 clients in
1996, and 1344 clients in 1997. Over 15,000 health care related web sites were reported
in 2000 (Dunaway 2000). While many of these are telehealth and referral, if only 5% are
counseling and therapy sites, and if 1997 statistics are applied to that 5%, nearly 100,000
clients are presently receiving mental health services via the Internet in the absence of
empirical data to support the efficacy of this service. Of Powells respondents, 85%
primarily used email for their Internet service; however 33% of these counselors had chat
capability and none were using virtual reality technology. These figures do not include
peer-moderated electronic bulletin board, peer-moderated chat rooms and private
messages.
Counseling issues included relationship issues, depression, family issues,
substance abuse, and anxiety (Powell 1998). In 2001, the organizers of the
HealthyPlace.com website both list and recruit mental health professions, creating a
network of referrals and some measure of credential verification. Members are
encouraged to provide supervised web sites, called communities, in the areas of abuse;
ADD/ADHD; addictions; alternative mental health; anxiety and panic disorder; bipolar
disorder; chronic pain; depression; dieting; eating disorders; gay, lesbian and transgender
issues; obsessive-compulsive disorder; parenting; personality disorders; relationship; self
injury; and sex/sexuality. Partners are encouraged to manage a complete website, write
a topic specific column, be the communitys ask-a-doc columnist, maintain a
journal/diary, manage an e-zine or write an Internet newsletter. Holmes (2001) whose
screening appears to be more selective, has links to over 700 counseling sites The owners


78
participants sessions. Sessions were downloaded with the permission of the participant
for further research analysis outside the scope of this study.
Nine graduate students and one recent graduate from the Department of
Counselor Education or the Department of Rehabilitation Counseling were trained in the
study protocol, study logistics, cognitive behavior therapy principles, WebCT use,
Internet Resources for clients, and research on the typical personal growth issues of
undergraduates. All trainings were conducted in person by the principal investigator who
prepared the extensive, detailed manual each facilitator received. Additional computer
specific training was provided by the principal investigator and by University personnel
familiar with the WebCT resources. The principal investigator coordinated with the
instructors for the interpersonal communications, substance abuse, student development,
and stress management classes to present the study during class early in the term and
recruit participants. Participants were contacted individually, randomly assigning to one
of the two conditions, scheduled for first session, given any direction needed for finding
the counseling lab or WEBCT chat room. The principal investigator was available via
beeper during any sessions to insure the safety of participant and availability to the
graduate student facilitators. Facilitators received weekly supervision in accordance with
their program requirements (practicum, research, registered intern, and such) and project
design.
The participants presented genuine concerns common to college undergraduates
such as but not limited to adjustment to college life, time management, study habits,
career indecision, roommate relations, and so forth. The facilitator contacted each
participant to set up the first meeting. He or she gave directions for participation. When


6
treatment, or a Huichol peyote ceremony, even though these practices are far more
ancient and continuous than modern psychology and have anecdotal efficacy (which,
admittedly, is difficult to quantify). In the modem era of scientific understanding and
explanations, physical illness and emotional distress have been dichotomized and
spiritual meaning has been severed from the treatment arena. Postmodern
disappointment with the limitations of science has revisited issues of holistic medicine,
prayer, faith, sympathetic magic (e g., crystals), imitative magic (e g., smoke, feathers)
and worldview in the relief of distress. The same is projected for the postmodern era and
cyber counseling.
Notably, all pre-modem and modern treatments recognize the value of a helping
relationship between the helper and the person seeking help, and a satisfactory outcome.
The outcome must be satisfactory in many or most cases or the method would have
become extinct, or at least superceded by major reformulation (e.g., trepanning to high
technology brain surgery, leaches to lancing).
Disembodied, asynchronous, and globally accessible therapeutic models will
expand the limits of thought and theory about the necessary and sufficient conditions of
therapy and the nature of therapy. Language and overt self expression have always been
the working matter of counseling i.e., Freuds talking cure however, language and
imagination will predominate in cyber counseling and will require new
conceptualizations of the essence of language in a polyglot world community (Shotter
1993). The language of the Internet is English, American English (Fink 1999). English is
the lingua franca of commerce and science. Internet therapy were influenced, limited and
contaminated for clients whose native language is not English even though they may


52
of short term therapy, Ellis mentioned that at least 1000 empirical studies. tend to
show that short term therapy at least when it is done with CT or REBT definitely is as
effective or more effective than other kinds of therapy and more effective than the
therapy that is given to control groups (p. 4) He further cautioned White, de Shazer,
Watzlawick and other brief therapy authors that they had better not use the generic term
brief therapy to imply that they are the only form of brief therapy.
Ellis (Palmer & Ellis 1995) was trained in psychoanalytical therapy but realized
that it takes a fairly long time to get people to free-associate, analyze their dream and go
over and over their childhood and later historical material. He describes his early work
as psychoanalytically oriented as opposed to classic psychoanalysis. I found out, to my
surprise ...that it was better, got better result than classical analysis... you quite quickly
get their basic history (p. 68-69). He continued REBT is intrinsically more efficient
and briefer. Often during the very first session I can show people the ABCs of distress. ..
. So REBT is sometimes successfully done in a few sessions (p. 69).
In his book on brief therapy, Ellis (1996) affirmed that REBT can be
accomplished with self help materials including books and cassettes that teach the REBT
principles Edelstein (1996) advocated three minute REBT sessions applied twice a day
focused on Ellis construct of musty thinking. He demonstrated that one session can be
sufficient to teach the principles of Rational Emotive Behavioral Therapy and involve the
client in three-minute techniques. In the forward to Edelsteins book, Ellis, founder of
REBT, says Of course it takes significantly longer than three minutes to dislodge the
many dysfunctional aspects of a troubled personality. But the clear and simple exercises
advocated by Dr. Edelstein, exercises, which are totally consistent with my principles of


28
emotional context, for making content explicit and for making the here-and-now process
comments so vital to counseling, in text talk.
Another equally interesting concept is hyper-personalization. Walther (1996)
introduced the concept of a reinforcing feedback loop, which he called an intensification
loop. He suggested that a person can project his or her idealized self into the
communication and be reinforced for that idealized self, increasing the realization of that
ideal in their daily off computer life via ego strengthening. He also suggests that when
communicators do not have to pay attention to social cues they pay more attention to the
text and its meaning. He did not, however, discuss whether this enhances or distracts
from therapy.
Patterson (2000) and Riemer-Reiss (2000) each reviewed Internet rehabilitation
service delivery and concluded that the Internet offers accessibility, immediacy,
advocacy, and competency for rehabilitation counselors and their consumers and also
challenges and ethical considerations. Patterson mentioned the availability of vocational
information, Department of Labor Statistics, job banks, placement resources, medical
information, free or inexpensive assessment tool (e g., Keirsey Type Indicator, Career
Interest Game, Career Key, Birkman Method Career Style Summary and the Self
Directed Search), support groups and continuing education. Patterson advised
judicious use to complement the work of human interaction.
Mutual trust or trustworthiness
Trustworthiness, consisting of dependability, reliability and honesty, is essential
to a good counseling relationship (Ainesworth 1995). These mirror the qualities Rogers
(1957) included in what he considered necessary and sufficient conditions for person
centered therapy to be effective. Trustworthiness, on the Internet has been researched by


67
The origin of the GAF is the Health Sickness Rating Scale (HSRS) developed in
1962. It consisted of thirty case studies and seven scales ability to function
autonomously, seriousness of symptoms, degree of discomfort, effect on
environment, utilization of abilities, quality of interpersonal relationships, and
breadth and depth of interest. A single score results as is true for the GAF. These scale
concepts can still be identified in the descriptions of the levels of functioning in the GAF.
The Global Assessment Scale (GAS) was a simplified form of the HSRS and has a .9
correlation with the HSRS. The GAS more closely resembles the GAF, in that it no
longer has scales or case studies. The descriptions illustrate each 10-point range on a
scale from 0 to 100. The GAF was identical to the GAS except it had a range of 0 to 90
in the DSM-III-R, however the scale has been returned to 0-100 in the DSM-IV.
(McCullough 1993). Other recommended instruments to be included in a core battery
are the Beck anxiety and depression inventories, the Hamilton anxiety and depression
rating scales, the psychiatric status schedule, the social adjustment scale, the Health-
Sickness rating scale, the MCMI, the Wisconsin Personality Disorders Inventory and
such. These measures however are more appropriate to a clinical population that allows a
statically significant range of change. Nations such as Australia and New Zealand who
have social health care have conducted extensive outcome scale development and
utilization studies (Eisen et al. 1999, Preston 2000). While these instruments are much
more concise and economical than the battery of tests recommended by McCullough,
they are again more geared to the outcome of clinical populations.
Consumer satisfaction is a business and marketing concept, which seems to have
entered the health care environment with managed health organizations. Employee


14
have researched temperaments and their contribution to the manner in which people
prefer to learn either in a formal educational setting or in life in general. This more
pervasive learning style was examined as well as the academic specific learning style
developed by the Wichita Public School System. Computer-mediated communication,
computer-mediated social presence, cognitive events, cognitive processes, cognitive
schemas, learning style, personality type, and working alliance are the major constructs
that form the theoretical foundation of this study.
Statement of the Problem
It has long been the sin qua non of the helping professions to Do No Harm.
Clients seek counseling because they perceive it offers hope, help, assistance, and
guidance in a time of confusion, pain, loneliness, or danger. Professional and
governmental agents exist to assure clients that the professional from whom they seek
help is trained, qualified and practicing in a safe and proven manner. Insurance
companies and other third party payers often refuse to reimburse any treatment that is
considered unproven or experimental. When new methods are developed, they must be
reproducible and scrutinized by the professional community to insure that they are safe
and effective. It cannot be assumed that when there is major change in the manner in a
service is provided, the therapy is identical to previously validated methods. Internet
counseling must meet the same standard of applicability and efficacy that is required of
all other modes and forms of counseling. Research must inform clinicians regarding
appropriate selection of clients who are likely to benefit from Internet counseling and
must demonstrate useful theory and techniques in the cyberspace-counseling
environment. One size does not fit all, and one technology certainly does not fit all.


59
Temperament Learning Styles
A second widely used learning style indicator has been developed by educators
using the MBTI temperaments (rather than types). The learning styles are
SensingPerceiving (SP), SensingJudging (SJ), iNtuitingThinking (NT) and
iNtuitingFeeling (NF). Dean (1997) noted that these four personality were recognized as
early as 450 B.C.E. These four temperaments are found in the sixteen types associated
with the Gallagher (2002) describes people with the SJ temperament as guardians of
tradition or traditionalists, learning from the past. People who prefer to use the SP
functions are artisans and experiencers who learn best from their own work and
experience. People who draw primarily upon the NT functions learn best conceptually
looking for rationale, explanation, theories and hypotheses. People who depend most
strongly on the NF functions are seen as idealists and learn inductively.
Sensing Perceiving
\
Dean (Dean, 1997) proposed that people using the SP function combination or
temperament are similar to those CITE. describes a kinetic tactile, preferring hands on
and active learning situations, which offer the opportunity to construct, operate and
manipulate objects.
Sensing Judging
People using the SJ learn best when their classroom, counseling environment, or
other learning situation provides clear expectations and a right way to do things. Clear
directions, specific extra-therapy assignments and an overtly structured session are
valuable assets to learning for those using the SJ functions


93
Working Alliance Inventory Bond (Client)
There were no significant main effects or interactions for the dependent variable
working alliance (c) bond,(Table 9).
Working Alliance Inventory Task (Client)
There were no significant main effects for independent variables by WAI (c) task
sub scale (Table 10), however there was a significant interaction between condition and
gender (F= 3.92, p = .05). Unlike the scores on the Outcome Satisfaction Questionnaire,
where lower scores were more positive than higher scores, the Working Alliance
Inventory is scored so that the higher the score the great the positive response. Table 11
shows the means and standard deviation for gender by condition.
Table 9. Source table for dependent variable WAI (c) Bond sub score
Sources of Variance Type III Sum df Mean F Sig.
of Squares Square
Corrected Model
Intercept
Condition
Gender
Ethnicity
Academic Learning Style
Introversion/ Extraversin
Temperament Learning Style
Condition by Gender
Condition by Ethnicity
Condition by Academic Learning Style
Condition by Introversion/ Extraversin
Condition by Temperament Learning Style
Error
1550.132
19
81.586
.914.568
43334.786
1 43334.786485.237.000
2.012E-04
1 2.012E-04
.000.999
9.003
1
9.003
.101.752
312.180
2
156.090
1.748.179
180.325
2
90.162
1.010.368
6.755
1
6.755
.076.784
461.944
3
153.981
1.724.167
7.433
1
7.433
.083 .774
232.154
2
116.077
1.300.277
18.941
2
9.471
.106.899
.261
1
.261
.003 .957
358.995
3
119.665
1.340.266
9109.254
102
89.306
266883.000
122
10659.385
121
Total
Corrected Total
a R Squared = .123 (Adjusted R Squared = -.030)
Male participants reported greater task development congruity (M = 34.14, SD =
8.32) with their facilitator in the face to face than in the computer-mediated sessions (M =


147
Cheskin Researchers. (1999). Ecommerce Trust Study. 33: Cheskin Research.
Retrieved 07/08, 2001, from the World Wide Web:
http: //www. sapient. com/cheskin/ assets/images/ etrust. pdf.
Christmas, W. A. & Turner, H. S. (2000). Should college health providers use E-
mail to communicate with their patients? Two points of view. Journal of American
College Health. 49 (July). 21-28.
Calo, J. A. (1982). Accountability revisited: The arrival of client outcome
evaluation. Evaluation and Program Planning. 5 (1), 31-36.
Clarkson, P. (1995). The therapeutic relationship in psychoanalysis, counselling,
psychology, and psychotherapy. London, UK: Whurr Publishers Ltd.
Colon, Y. (1994). Chatter(er)ing through the fingertips: Doing group therapy
Internet [web document]. Women and Performance. Retrieved 2/15, 2001, from the
World Wide Web: http://www.echonyc.com/~somen/Issuel7/public-colon.html.
Commission on Rehabilitation Counseling Certification. (2002). Standards of
Ethical Practice (draft 2). [web document].CRCC. Retrieved 08/12 2002, from the World
Wide Web: http://www.crccertification.com/html/draft2.php.
Cooper, S. & Archer J., Jr., (1999). Brief therapy in college counseling and
mental health. Journal of American College Health. 48 (July). 21-28.
Cummings, N. (1990). Brief intermittent psychotherapy throughout the life cycle.
In J. L. Wells & J. E. Lianetti (Eds ). Handbook of the brief therapies (169-184) New
York, NY: Plenum.
Curtis, H. C. (1979). The concept of the therapeutic alliance: Implications for the
widening of scope. Journal of the American Psychoanalytic Association. 27. 159-192.
Dansky, K. H., Colbert, C. J. & Irwin, P. (1996). Developing and using a patient
satisfaction survey: A case study. Journal of American College Health. 45 (2), 83-88.
Davidson, C. T. & Jackson, M. (1996). The web we weave: Using the Internet for
counseling research. Part I [web document]. Counseling Today Retrieved 06/20 2001,
from the World Wide Web: http://www.counseling.org/members/ctonline/archives/web
htm.
Dean, D. (1997). Learning styles of psychological types [web document], author.
Retrieved 05/07 2002, from the World Wide Web:
http ://www. dougdean. com/leamingstyles/index. cfn.
Delaney, H. D. (1978). Interaction of individual differences with visual and verbal
elaboration instruction. Journal of Educational Psychology, 38. 312-314.


124
Session Structure Guidelines
Condition 1 Face-to-face
Session 1 Face-to-Face: 60 minutes
Goals: To engage the participant in collaborative, cognitive personal growth counseling
Objectives: To develop rapport with the participant
To clarify the therapy process to be used
To identify and clarify the participants issue-based goal
To collaboratively develop a set of tasks to accomplish the goal
Session 1: The facilitator will welcome the participant and answer any questions.
The purpose of the first meeting is to begin to establish a bond between the facilitator and
the participant, explain the nature, language and methods of the CBT sessions, identify
the goals and tasks to be accomplished and make the next appointment. For face-to-face
sessions this means discussing therapy conventions of freeze frame, stop action, focus on
here and now, and other as listed in the training manual. For the computer-mediated
sessions, the focus on here and now, cognitive reframing and homework are similar to the
face-to-face session, however the subtle therapeutic interventions will differ in that rather
than non verbal vocalizations, facial expression, body language and visual/spatial
environment the action literally in the face-to-face session, the research assistant will
teach and use bracketed emotions, descriptive immediacy, and textual visualization. The
participant will need to practice these with the research assistant prior to the experiment
until he is comfortable and confident using them.
Session 2 Face-to-Face: 60 minutes
Goals: To continue to build rapport and to process work to date
Objectives: To continue to develop rapport with the participant
To review independent participant work to date
To process experiences relevant to tasks and goals since last session


131
Screen Shot 2 Submission option from previous screen shot. Note the blue highlighted
next page button ~ that means there are more pages with lists. Once you go past page 1
the previous page box will also be live blue lighted, blue
unit ir.twnef f uriuM* pnvxtert bv A1 $ T WorMNi* 'jftrvfre
f§£3
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Submissions: MBT
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Screen shot 3 Using the detail hot link you can see the participants actual responses. I
sincerely request that you not do this for the participants privacy and confidentiality.
There is no way I can block this option in WEBCT so I am trusting each of you to respect
the participants privacy.


44
site indicated that a web site should not be used to advocate or promote the following:
any illegal activity, activities that support or espouse non consensual and/or extreme
violence or sexual aggressiveness toward another individual or group for any reason,
activities that support or espouse hatred towards another individual or groups based on
any criteria and activities and input from individual that violate our inclusive standards
http ://mentalhealth. about. com While these are laudable criteria, they fall short of
mental health professional practice criteria.
Clinicians Yellow Pages http://mentalhelp.net/mhn/yellowpages/; Whos Who in
Mental Health on the Web http://idealist.com/wwmhw/; Find-a-Therapist; and 1-800-
Therapist; list web site for an annual fee, without evaluation or monitoring, similar to a
listing in the Yellow Pages of a telephone directory.
Basically, a psychotherapist practicing on the Internet must establish all the same
security, authenticity, and grievance procedures as the psychotherapist seeing clients in a
physical office. A physical office has a pleasant, soothing decor, locks on the doors,
security system, secure location and procedures for charts, requests for notes and so forth.
In physical office, a therapist must display, at minimum, the occupational license and the
professional license to demonstrate authenticity and grievance resources. The virtual
office needs an effective web site that is uncluttered, appealing, and easy to navigate.
There must be firewall(s) protecting the therapists computer system, SSL across the
network and easy instructions for client firewalls (locks on the doors). Authority to
practice is demonstrated by posting live logos (i.e. licenses) for security (e g., Verisign)
and credentials (e g., @HON). Live logos are linked to the company and the client can
instantly verify the therapists legitimacy to the extent of each authoritative bodys


Credential Validating Referral Sites
Advantages of Internet Counseling
Disadvantages of Internet Counseling
Cognitive Behavioral Counseling Models
Cognitive Behavior Therapy
Brief Cognitive Behavior Therapy
Using Brief Therapy with Undergraduates
Undergraduate Personal Growth Concerns
Individual Information Processing Differences
Demographic Factors
Learning Style Theory
Academic Learning Styles
Temperament Learning Styles
Learning Style Conceptualization Comparison
Measuring Information Processing
Personality Attitudes
Measuring personality attitudes
Counseling Process and Outcome
Working Alliance
Measuring Therapy Outcome
Application in this Study
3 METHODOLOGY
Statement of Purpose
Hypotheses
Descriptions of Variables
Dependent Variables
Independent Variables
Population
Sampling Procedures
Data Collection Procedures
Instrumentation
Working Alliance Inventory (Client)
Working Alliance Inventory (Therapist)
Outcome Satisfaction Questionnaire
Myers Briggs Type Indicator Form M (MBTI)
Center for Innovating Teaching Experiences Learning Styles Inventory (CITE)..
Demographics
Data Analyses Procedures
4 DATA ANALYSIS
Descriptive Statistics for Dependent Measures
vii
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68
Assistance Programs (EAP), social work and rehabilitation counseling seem to be on the
leading edge of development of these instruments, however, reliability and validity has
not been rigorously demonstrated. The consumer satisfaction survey is, nonetheless, the
most appropriate outcome measure for this study of undergraduate students presenting
with developmental and growth issues. Attkisson et. al (1982) developed a college
student satisfaction form that was too specific in it items and too long (82 items) to be
used in this study.
An outcome satisfaction questionnaire was developed for this study using the
work Dansky, et al (1996) as a guideline. The items developed were submitted to a
committee of experts (e g., Delphi Method for evaluation and were used by counselors
and students in a pilot study at a local community college. Counselors and students were
asked to respond to each item based on their experience at the counseling center and to
offer content, wording, and face value feedback regarding each item. The resulting
instrument consisted of two forms, one for participants, and one for facilitators. The
participant form had 12 items, seven Likert-like items about satisfaction with the personal
growth sessions outcome, two Likert-like items assessing the participants self perceived
computer competence, and one Likert-like items eliciting the participants predicted
future uses of computer-mediated counseling. Two items were open-ended qualitative
questions requesting the participants opinions about the personal growth sessions. The
computer-mediated aspect was specifically targeted in the qualitative questions to allow
the participant to appraise his or her experience regardless of assignment to conditions of
the experiment. The facilitator version had similar session focused items but did not have
the qualitative items, the computer competence items, or the predicted future use items.


Ill
these issues did lead to referral to formal University or College counseling resources.
Nonetheless, persons motivated to locate and pay for Internet counseling will presumably
be experiencing more serious problems, have fewer personal coping resources, and/or a
greater perceived need for services. The results of this study may or may not generalize
to the population most likely to use Internet services. Further study must incorporate this
population. A study of a clinical population could use any of a number of more
objective, statistically validated outcome measures discussed in chapter 2 of this paper.
Clinical
College students were willing to discuss serious personal growth issues over the
Internet with a facilitator they had never met. They had certain assurances, to be sure,
including but not limited to a copy of the Institutional Review Board contact phone
number and email address. They met with the principal researcher in person when she
recruited in their classroom. They had access to the department and the dissertation
committee chairperson through their classroom instructor. They were advised of the
specific campus resources available to them as students, should their issues require crises,
counseling, psychological or psychiatric intervention. People without these immediate
and serious recourses also seem to be willing to disclose private intimate information
over the Internet. Given the number of counseling web site that exist, clinicians must
provide protection for vulnerable clients and must also consider ways to protect their own
professional integrity. Students did not ask if the project was safe and approved by the
University, they were given specific documentation that described their responsibilities,
protection, resources, and recourses. The Web counselor should be expected to provide
the same information to potential clients.


95
Working Alliance Inventory client subscale goal
There were no significant main effects or interactions for the dependent variable
working alliance total, participant version. Table 12 lists relevant statistics.
Table 12. Source table for dependent variable WAI (c) Goal sub score
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F Sig.
Corrected Model
Intercept
Condition
Gender
Ethnicity
Academic Learning Style
Introversion/ Extraversin
Temperament Learning Style
Condition by Gender
Condition by Ethnicity
Condition by Academic Learning Style
Condition by Introversion/ Extraversin
Condition by Temperament Learning Style
Error
Total
Corrected Total
1176.827
19
61.938
.961
.512
12382.566
1 12382.566192.211
.000
105.700
1
105.700
1.641
.203
23.255
1
23.255
.361
.549
14.336
2
7.168
.111
.895
161.415
2
80.707
1.253
.290
5.503
1
5.503
.085
.771
231.919
3
77.306
1.200
.314
90.501
1
90.501
1.405
.239
102.026
2
51.013
.792
.456
6.826
2
3.413
.053
.948
33.275
1
33.275
.517
.474
208.935
3
69.645
1.081
.361
6571.010
102
64.422
81420.000
122
7747.836
121
R Squared =152 (Adjusted R Squared = -.006)
Facilitator Dependent Variable Analysis
Facilitators completed the facilitators version of the Working Alliance Inventory
and of the Outcome Satisfaction Questionnaire. Unlike participants, the facilitators were
not asked to report their predicted future use and computer/Internet skill and comfort
levels in these surveys. Those factors were discussed at length in individual debriefing
sessions with each facilitator, but do not appear in these analyses.


103
condition than in the face-to-face condition. Females were able to develop tasks equally
well in either condition.
From the facilitators point of view, female participants were better able to
develop an overall working alliance, than males. Female were better able to collaborative
develop goal oriented tasks, than males (perhaps because they were equally good at
developing task in each condition). Females were better able to define their goal for the
personal growth sessions. There were significant findings for experimental condition.
Males were better able to develop a bond with their facilitators in the computer-mediated
condition. Task development was better achieved in the computer-mediated condition.
Goal definition was more precise in the computer-mediated condition. While the
evidence is not definitive, it is certainly consistent enough to suggest that individual
differences do contribute to counseling process and outcome efficacy and should be
further investigated.
Qualitative Analysis
Comprehensive qualitative analysis of the data collected is outside the scope of
this project. However, some material is presented to illustrate and confirm the constructs
presented in Chapter 2 presence, trustworthiness, and intimacy. Some participants
expressed positive reactions to their experiences in the computer-mediated condition.
Comments from participants are replicated without change except when it was necessary
to replace the facilitators name with facilitator in two comments. Grammar and spelling
are explicitly overlooked for the sake of spontaneous communication during a session
therefore those errors remain in the survey comments. The surveys were all completed
on the Internet, and participants reasonably responded with the same disregard for writing
mechanics as those in the computer sessions has been instructed to do.


76
scheduled for sessions. Upon the completion of three personal growth sessions, the
participant completed the MBTI, the CITE, the WAI (c) and the OSQ (p) in an encrypted
website monitored by a survey technician available in chat room 5 of the site who was
trained to answer any questions about the mechanics of completing the instruments that
arose. The facilitator, who was not the monitor, completed the WAI (t) and the OSQ (f).
Sampling Procedures
Volunteers were recruited from the population of students enrolled in
undergraduate counseling education classes in interpersonal skills and stress
management. Most participants received a small amount (no more than 2% of grade) of
class credit for participation and three sessions of personal growth guidance. Participants
were quasi-randomly assigned to the twelve facilitators and were randomly assigned to
face-to-face or computer-mediated study conditions. Exceptions were made to random
assignment to facilitators if the facilitator knew the participant or if the facilitator and
participant were unable to find a mutually convenient time to meet. The facilitator each
conducted an equal number of face-to-face and computer-mediated sessions. Pre
induction paperwork included an informed consent, assurance that volunteers are at least
18 years of age, and provision of a code for confidential contact, a phone number, and/or
an email address. All volunteers had adequate computer ability so that they could be
randomly assigned to conditions. The university requires these skills of undergraduates
and requires all undergraduates to own or have access to a computer with sufficient
application software to participate in this study. The computer-mediated sessions were
conducted in the university electronic learning gateway system WebCT. Many classes
are offered or supplemented through this system so all students can be expected to learn
how to use it at some point in their undergraduate career. The university has a computer


105
Intimacy not getting the comfort of being in the same room as
someone who is listening and caring
Ambivalent responses included:
Facilitator was very good and I felt very comfortable with her. I think I
would have preferred to be in-person though.
When online with your therapist you never know what they are doing,
thinking or saying at that moment. Being online takes away the personal
aspect of it. However, I do think that the computer sessions would be a
good back up like if the person had to go out of town on business or
something
Some participants offered observations about the mechanics of Internet counseling that
can get in the way of counseling.
Most people think faster than they can type so it can be frustrating in the
chat rooms at times. You have a lot to say but it takes a long time to get it
out. Much different than talking on the phone or in person
Having to type stories that are really long
I had some distractions in my room when we were talking.
it felt like a lot of time was wasted waiting for messages to go back and
forth cause i was using my home dial-up computer that is sometimes alot
slower than a T3 or dsl connection


122
know what size you need for your recorder. If you do not have a recorder, one will be
provided for the duration of the experiment. Session should last 50-60 minutes. If the
session is shorter or longer than the norm, please make a note why. It is fine; I just need
to know why. Tapes, clocks, tissue, manila envelopes and any new handouts will be in
the team mailbox so please check it regularly. If you leave materials be sure they are in
sealed envelopes for privacy,
COMPUTER-MEDIATED CONDITION Entering your participant into the WebCT
system is a two part process. Each participant has the last name Participant, and the first
name alphanumeric code because these show up in the chat room. Do not use the
participants name. Use the code for the password to keep things simple and private.
Use the code plus the numeral 1 to create a second account where you can complete the
facilitator surveys for this participant (Your regular access level is TA and as such you
can see but not do the surveys). WebCT automatically stores all dialogues so this privacy
is paramount. If your participant already has a Global ID from another class, he or she
must not use it for this study because it would be recorded.
The chat room format in WebCT is designed for class access, not individual
access therefore a participant might enter your session. Please be very assertive in asking
them to leave and return at their scheduled time. Checking the chime entry box will help
you notice if someone does accidentally enter. I do not anticipate this being a problem
but be aware it could occur and be prepared to handle it. If two facilitators have
scheduled a chat room for the same time, one should move to any empty chat room 1-4.
Please do not use 5 or 6 with participants except as noted below.


143
PARTICIPANTyes
FACILITATORgood. so, it is about that time that we should go, any
questions before we end? I will see you next week at this time
FACILITATORthat was a question israile?}
FACILITATORoops againl
FACILITATORhe he
PARTICIPANTyes
PARTICIPANTlol
PARTICIPANT:-)
PARTICIPANT! enjoyed myself
FACILITATORgood, so did I!
FACILITATORSee you next week!
PARTICIPANT! never really talk about myself
PARTICI PANTbye
*-**** FACILITATOR left EDU_DISS_Rooml. Time: Mon May 20 18:21:54 2002
*-**** PARTICIPANT left EDU_DISS_Rooml. Time: Mon May 20 18:22:00 2002

Session in EDU_DISS_Rooml ended (all PARTICIPANTS have left).
Time: Mon May 20 18:22:00 2002



Participant Dependent Variables Analysis 86
Predicted future use (participant) 88
Level of Computer/Intemet Skill 90
Outcome Satisfaction (Participant) 91
Working Alliance Inventory Total (Client) 92
Working Alliance Inventory Bond (Client) 93
Working Alliance Inventory Task (Client) 93
Working Alliance Inventory Goal(Client) 95
Facilitator Dependent Variable Analysis 95
Outcome Satisfaction Questionnaire 96
Working Alliance Inventory Total (therapist) 97
Working Alliance Inventory Bond (therapist) 98
Working Alliance Inventory Task (therapist) 99
Working Alliance Inventory Goal (therapist) 101
Qualitative Analysis 103
5 SUMMARY, CONCLUSIONS, AND IMPLICATIONS 106
Summary of the Study 106
Limitations 108
Implications and Recommendations 110
Research 110
Clinical Ill
APPENDICES
A FORMS AND INSTRUMENTS 114
Participant Contact Sheet 114
Informed Consent 115
Outcome Satisfaction Questionnaire 117
B FACILITATOR TRAINING MANUAL 120
Table of Contents 120
Logistics 121
Session Structure Guidelines 124
Therapy Plan and Progress Notes 127
Facilitator Checklist 128
Sample of tracking sheet 129
WebCT samples screens 130
Required Reading Study Protocol 132
Required Reading College Student Counseling 133
vin


56
same. The same is assumed to be true between 1993 and 2002; however it recognized
that the wide spread access to the Internet, the university requirement of personal student
ownership or ready access to computers, the use of Web based and distant learning and
the events of 9/11/01 may have generated new categories of concern not relevant in 1985
or 1993 although no such new categories were observed in the present study.
Individual Information Processing Differences
Many factors have been demonstrated to influence how individual process
information such as therapy input and tasks results. Some of these include environmental
and cultural variables such a race, gender and ethnicity, brain lateralization with emphasis
on processing information verbally or with images, and personality traits including
introversion and extraversin.
Demographic Factors
The major premise of the huge national investment in Telehealth/Telemedicine is
that technology provides a method to reach under served populations women,
undereducated citizens, rural citizens, Native Americans, citizens with disabilities, and
citizens of color (HCFA 1996, HCFA 1999). The concern of researchers (Reid 1994,
Powell 1998) is that the price of technology, and the education and experience required to
uses these resources may effectively exclude the very populations it is thought to most be
able to benefit. Powell (1998) found that the majority of Internet therapy users were
male.
Learning Style Theory
Learning style, brain lateralization, and information processing research and
theory have contributed a substantial body of information indicating that people encode,
process and retrieve information in distinctly different manners. Two style systems are of


136
FACILITATORThe next two sessions will be pretty much the same,
except hopefully I won't have to spend that time in the
beginning explaining
PART ICI PANTo ka y
FACILITATORAbout halfway through the third session, we will finish
up and then I will guide you to the quizes that you take at the end,
there are 4.
FACILITATORAny questions so far?
PARTICIPANTnope :-)
FACILITATOROk, then . .
facilitatorthe first thing I want to talk to you about is
confidentiality. Basically, what is said {actually,^written* here is
confidential, except that Martye(the one who* doing this for'her
dissertation) will have access to it
FACILITATORbut . there are some exceptions to that confidentiality
PARTICIPANTwhat are they
FACT r.TTATORthat is if i think you are in danger to yourself or
others,; or if X suspect child abuse# ^elde*! abuse, or abuse of
individuals / disabilities.. In that case, l would have to report it to
the proper authorities. But, dont worry, X would never do that without
first talking to you about it first
FACILITATOROther than that, what is said here, stays here. Make
sense so far?
PARTICI PANTyes
FACILITATORcool FACILITATORthe only other thing I wanted to say a little about is .
FACILITATORthat counseling is a little different than other
relationships inasmuch as it is all about you
PARTICIPANTok
FACILITATORyou are free to ask me questions if you want, even if it
is personal, but I will always hestitate to answer to make sure that the
conversation doesn't change to focus on me, cuase that's not the point
PARTICI PANTok
FACILITATORand that also, you are really doing the counseling, all
day everyday, and the sessions themselves are more like checkups or
coaching sessions


72
Ho3b: There is no significant relationship between in the outcome efficacy
and gender in CM Counseling.
Ho3c: There is no significant relationship between the client reported quality of
the working alliance and gender in F2F counseling.
Ho3d: There is no significant relationship between the outcome efficacy and
gender in F2F Counseling.
Ho4a: There is no significant relationship between the client reported quality
of the working alliance and ethnicity in CM Counseling.
Ho4b: There is no significant relationship between the client reported
outcome satisfaction and ethnicity in CM Counseling.
Ho4c. There is no significant relationship between the client reported quality of
the working alliance and ethnicity in F2F counseling.
Ho4d: There is no significant relationship between the outcome efficacy and
race/ethnicity in F2F Counseling.
Ho5a: There is no significant relationship between the client reported quality
of the working alliance and visualizing learning style in CM Counseling.
Ho5b. There is no significant relationship between the client reported
outcome satisfaction and visualizing learning style CM Counseling.
Ho5c: There is no significant relationship between the client reported quality of
the working alliance and verbalizing learning style in F2F counseling.
Ho5d: There is no significant relationship between the outcome efficacy and
verbalizing learning style in F2F Counseling.
Ho6a: There is no significant relationship between the client reported quality of
the working alliance and introversion in CM Counseling.
Ho6b. There is no significant relationship between the client reported outcome
satisfaction and introversion in CM Counseling.
Ho6c: There is no significant relationship between the client reported quality of
the working alliance and extraversin in F2F counseling.
Ho6d: There is no significant relationship between the outcome efficacy and
extraversin in F2F Counseling.


61
86-item Ways of Thinking Questionnaire. The questionnaire was normed using junior
high school students.
While Richardson examined information processing in social psychology,
education psychologists Babich, Burdine, Albright and Randol (1976), developed a
learning style inventory, which is widely used today. They targeted three areas of
concern information processing, work conditions and expressiveness preference. It is
the information processing visualization, verbalization that parallels the social
psychology work. Items were drawn from the same source material as the Visualizer
Verbalize Questionnaire, has more extant reliability and validity data, is published and
readily available, and has been used extensively in education, adult education, career
counseling and vocational rehabilitation. The Center for Innovative Teaching Experience
Learning Style Inventory (C.I.T.E.) is used by the Veterans Administration and public
school districts across the country to identify learning styles and to guide instructors,
counselors and teachers in designing learning experiences to maximize the students= use
of their preferred learning style. The West Virginia Adult Basic Education program uses
the CITE as its primary assessment instrument to guide recommendations for tutorials,
adult learning experiences, and vocational training.
Myers and Briggs (1962) developed an extensively studied, widely used
assessment tool, the Myers Briggs Type Indicator (MBTI) to measure the individuals
trait preferences consistent with Jungs theory. There are four independent dimensions,
introversion/extroversion; sensing/intuititing; thinking/feeling and judging/perceiving.
Interpretation of the type involves hypotheses about the interactions of these
dimensions and involves understanding of dominant functions, auxiliary, inferior


22
good deal more complex than ordering a book from Amazon.com or a rose bush from
JacksonandPerkins.com. Is there a subjective component to human interaction in
cyberspace? Is there a person or psyche to counsel? Three major concepts have
been discussed at length social presence, trustworthiness and intimacy. These factors
create an environment in which a therapeutic alliance can be developed. One of the three
essential components of a therapeutic alliance is the development of a personal bond.
Social presence, trust, and intimacy or self-disclosure, create the milieu in which a
personal bond can develop between the therapist and client. The client and the counselor
need to experience a sense of bond, connection, or rapport. The bond can be based on
the sense of mutual trust, liking, understanding and care (Bordin 1976, Horvath &
Greenberg 1986).
Social Presence.
Is there social presence in cyberspace, and if so, how does it manifest? In
response to the gamut of pressures emanating from the war in Viet Nam and the Cold
War, government, military and related universities developed the technology to deliver
information around the world and into near outer space almost instantly. At the same
time, social, political, humanitarian and radical thinkers were developing experiments in
human living that were just as dramatic. The social geniuses of the era readily adapted
and defined the ultimate use of the Internet. Rheingold (1994) was perhaps the first
social thinker to systematically describe the social and cultural communities that
developed on the Internet. The WELL, a San Francisco founded, Internet community
dating from the early 1980s, grew out of the social activism, communal living
experiments, and democratic philosophies of the 1960s. The personal involvement and


46
PsychOptions site offers a sliding scale If you have extenuating circumstances and/or
are over 65+ and/or on a fixed income then you may contact PsychOptions to request an
adjustment and explain the reason why.
Disadvantages of Internet Counseling
Internet counseling is a double-edged sword. The disadvantages of Internet
counseling can be the same as the advantages immediacy, reliability and validity of
information, security (e g., privacy and confidentiality), anonymity, abandonment,
physical absence, ethics, legality, and security (Grohol 1996, Storm & Moreggi 1998,
Oravec 2000). While a potential client may be assured of a response within 48 hours
while a non-crises office client may have to wait a week or two for a first appointment,
the quality of that first contact may be no more valuable than the first phone calls to a
physical office and responses appropriately provided by trained office staff. The
credentials of the Internet counselor may be as valid as those of the office counselor;
however, it is generally more difficult to verify those credentials as demonstrated above
in the extensive discussion of web security. In a traditional office the client can examine
see the professional license and the business license, both of which are required by law
(at least in Florida) to be prominently displayed. The local Better Business Bureau and
Chamber of Commerce can both be contacted to check the counselors business history
and can offer recourse if problems arise.
As discussed above the web is developing comparable resources in @HON and
Metanioa.com, however they are not well known. Furthermore, in a physical site, the
client has recourse if credit card charges, personal checks and cash payments are
mishandled. Again the Internet offers security but many sites promise security (e.g.,
affordablewellness.com) when in fact they are not secure. Buyer beware is never more


27
Cyber counseling specific conventions have been developed and need to be
researched, developed, enhanced and expanded. Murphy and Mitchell (1998) developed
a three-component convention to provide a text-based alternative to the non-verbal cues
in traditional counseling. Technique 1 is called emotional bracketing. In the text of an
email or other text-based communication, the writer puts the emotional tone of his or her
thought in parentheses (p. 24). For example, a therapist may be concerned because the
client mentioned his car was stolen then skipped without elaboration to another topic.
The therapist might write. Let me interrupt here and return to your mention of your car
being stolen (concern, puzzled). What have you had to do as a result. . police, public
transportation, . .? I know you frequently have to take your aunt to doctors
appointment (proud of your commitment)? How are you coping (knowing you have)?
The second tool or technique Mitchell and Murphy developed is called
alternatively textual visualization or descriptive immediacy. They provided the
following example:
If you were standing beside me as I write this, Tanya,
you would notice me stopping often, falling back against
the back of my chair saying thats incredible to myself.
Your recent successes against guilt are so wonderful that
even now I find myself (right now!) Stopping in the
middle of the sentence, my hands towards the computer
screen, my mouth wide open as if to say this is amazing.
How did she defeat guilt? (p .24).
Third, Mitchell and Murphy encouraged the conscious, deliberate use of literary
tools simile, allegory, metaphor, poetry, story telling, and mythology commonly used in
face-to-face therapy. These techniques have expanded the repertoire available to
therapists well beyond the effective but static emoticon or smiley, for expressing


118
Question 9 How would you rate your Internet skills?
Internet guru good user skills adequate user skills novice skills Internet phobic
Question 10 Please tell us what you liked least about this experience.
Question 11 Do you have observations, reflections or comments, that have not been
addressed in these surveys, that you wish to share about being part of this study?
Question 12 How likely are you to choose computer mediated counseling should you
choose counseling at some time in the future?
Very likely likely not likely would not not sure
Outcome Satisfaction Questionnaire (facilitator form)
NB: This instrument was administered online in the WebCT survey function
using an application, Respondus, so the facilitator view varied from this. They
marked their responses by clicking in the appropriate radio button or text box, not
depicted below. The participant link was labeled Outcome Satisfaction Questionnaire but
the facilitator link was labeled Facilitator Survey 1 because all surveys were listed on the
same screen. It was a concern that the participants might try to second guess their
facilitators rather than offer their own frank opinions, if they knew they were completing
similar surveys. The same convention was used with the Working Alliance Inventory
label for participants and Facilitator Survey 2 label for facilitators.
Question I participant ID and facilitator initials
Question 2 The skills, abilities, and experiences that this participant learned directly
enabled him or her to reach the personal growth goal set for these sessions.
extremely satisfied very satisfied satisfied not very satisfied not at all satisfied
Question 3 Participant being able to apply the skills, abilities and experiences gained in
these sessions to resolve other stresses and concerns in life.


APPENDIX C
COMPUTER-MEDIATED SESSION TRANSCRIPT
This is a transcript of a computer-mediated session recorded by the WebCT
system and downloaded to the researchers computer. Only the researcher had the level
of access required to see and download these logs. The only editing removed the
participants identification code and the facilitators name. All spelling and grammar
remains as produced. Samples of the facilitators use of Internet counseling techniques
emotion bracketing and textual visualization, described in Chapter 2, are highlighted in
gray. Also noted in gray is the facilitators explanation of the limits of confidentiality
and the facilitators amplification of the participants use of the emoticon lol. Lol is
one of the most common emoticons used on the Internet but it is an acronym with
multiple meanings laughing out loud, lots of love, and lots of luck therefore it was
important for the facilitator to find the precise meaning the participant intended.
k^'k-k-k-kkk'kkick'k'kic-k-k'k'k-k-ie-kir-feiek'kk-k'k-k-kk-fe'k'k-ie-kk'k-kk-ir-kk-k-fr-k-k'kk-kk'k-k'tr-k-k-k-k-kk'k-k-k-k-fr-k-k'k'fir-k
k
New session has begun in EDU_DISS_Rooml.
Time: Mon May 20 17:02:27 2002
k^k-k-k-k-kkrir'k-k-k-k-k-kk-k-k'k-kk-k-kic'k-ir'k-k-kkkr^kk'k'k-k-kir-k-k-k-k-k'k-k-kie-k-k-k-kk-k-k-kk-k-k-k-k'k-kic-k-k-ic'k-tr-k-k-k-k
*+**** --FACILITATOR entered EDU_DISS_Rooml. Time: Mon May 20 17:02:27
2002
FACILITATORThis is Session one again for
*+**** PARTICIPANT entered EDU_DISS_Rooml, Time: Mon May 20 17:16:14
2002
PARTICIPANTsorry I got lost
FACILITATORHello, I just wrote you an email!
FACILITATOR
134


73
Descriptions of Variables
The research design consists of random assignment of participants to one of two
conditions. The conditions are face-to-face personal growth sessions and computer-
mediated chat room personal growth sessions. Because the participants were randomly
assigned to one of the two conditions, post-test only were used to measure the variables.
RO 3 face-to-face personal growth sessions Posttests
R1 3 computer-mediated personal growth sessions Posttests
The three sessions were conducted to facilitators who will work with an equal
number of participants in each condition, that is, if a facilitator works with a total of 10
participants, he or she will conduct three sessions face-to-face with 5 participants,
individually, and 5 sets of sessions via computer chat room. Ten graduate students
representing a broad population of counselors (1 male, 9 females; 1 African American, 1
Hispanic; 3 licensed mental health counselors, 3 certified rehabilitation counselors; age
range 23 to 56), from counselor education and rehabilitation counseling were hired and
trained to conduct the personal growth sessions. The participants received extra credits in
their counselor education interpersonal skills, substance abuse, or stress management
classes, at the discretion of their instructor. The quality of the working alliance and the
outcome satisfaction were measured to evaluate and compare the counseling experience
in the two conditions. The individual differences that participants bring to the experience
were measured to determine if any and which differences might predict better success
with one condition or the other. For example, do introverted participants do better in one
condition than they do in the other? Do African American participants benefit more from
one condition than they do in the other? Is there any difference in the working alliance
developed by participants with a verbal learning style in one condition versus the other?


36
Murphy and Mitchell (1998) developed techniques described above and wrote
about their qualitative observations from conducting therap-e-mail on their web site
http://www.therapvlntemet.ca. They required potential clients to complete and return an
on line form called the Virtually Solve It worksheet, which can be completed offline.
They believed that the permanent record of email makes consultation and supervision
easier. A response can be reviewed by the supervisor, consultant or peer prior to being
sent to the client (p. 26). The permanent potential of email encourages the therapist to be
thoughtful and behave in an ethical manner (p. 27). Clients found that filling out the VSI
and writing out their interactions with the therapist externalized their problems making
them easier to confront and resolve (p. 27). Repeated efforts to obtain this form were
unsuccessful, so it appears no longer to be a viable web service, however GrohoFs site is
active and has pre-therapy form at http://psychcentral.com.
Mitchell and Murphy recommended that further research should be conducted to
study the impact and effectiveness of their techniques (emotion bracketing and textual
visualization (descriptive immediacy); application of narrative and solution focused
therapy in face-to-face and electronic therapy; impact of writing itself in the therapeutic
process; and pre-treatment effect of writing to the therapist (e.g., using the VSI)( p. 30)
Chat/Conferencing
Suler (1997) describes text talk as austere because it lacks voice, facial
expression, body language and visual/spatial environment. While some may find this
disorienting, he suggested that for many, text-talk is a more direct, intimate mind-to-mind
communications approximating an internal dialogue. In his study, Suler analyzed
many megabytes of saved logs exploring the concerns that the absence of visual and
auditory cues confuse users, and lead to painful misunderstanding. He identified


58
environment is an individual difference in the ability to developed a therapeutic working
alliance and produce a satisfactory therapeutic outcome. As potential clients are
evaluated for cyber counseling, should their preference for verbal processing or visual
processing be considered?
Visual Learners
Maclnnis and Price (1987) summarized the role of visualizing in marketing as a
processing mode in which multisensory information is represented in a gestalt form in
working memory. The visualizers were found to use daydreams and fantasy in addition
to graphically and pictorial representations in problem solving. Babich (1976)
operationalizes the visualizing construct as the preference or ability to learn from seeing
words or numbers and remembering spoken information by writing it down.
Richardson (1983) found that the visualized s thinking processes consisted of pictorial or
visual images. The visualizer attended to the spatial layout, physical features, and
sensory input of information to be encoded.
Verbal or Auditory Learners
Babich, Burdine, Albright & Randol(1976) operationalized the verbalizing
construct as a preference for hearing words or numbers spoken and noted the common
practice of verbalizers to vocalize or move the lips or throat while reading written
materials. Richardson (1983) found that verbalizers thinking processes consisted of
spoken words or self-verbalizations, that is, linguistic encoding, labeling or naming. He
likened it to an experience of inner speech.


3
American living in Iceland. This was a personal recreational activity, not a professional
relationship. While both were using an AOL Dream chat channel, the person in Iceland
popped-in to the researchers screen via the private channel (instant messenger) when
the researcher mentioned that she lived in Jacksonville, Florida. The person in Iceland
had moved from Jacksonville Naval Air Station to the Iceland Naval Air Station and was
lonely. The researcher was familiar with both geographic locations, both Naval Air
Stations and with military-family life. The researcher assumed that the person with
whom she was chatting was a young wife of an enlisted sailor. The chat contents were
volcanoes, glaciers, lava beds, hot water lagoons, things to do in Reykjavik, Icelandic
mythology, other exotic locations familiar to both. The researcher terminated the
interaction when she learned that her cyber-friend was a 12-year-old girl. Nothing had
ever been discussed that was inappropriate when talking with a child. Nothing had ever
been discussed that the researcher had not discussed with hundreds of children that age
during her career as a natural history museum curator; however, a personal bias of how,
or when or for what reasons one related to a child had been violated (a surprising
revelation to the researcher). The girl in Iceland had never claimed to be anything other
than what she was a situationally lonely and resourceful kid who moved all too
frequently to become rooted in any conventional community, a person regardless of age
who was interested in relationship, friendship, computer communication and natural
history. One would think that age should not matter in this situation but it did. Most
saliently, it is precisely for this population (the geographically isolated) that telehealth,
telemedicine, and cyber-counseling are most strongly advocated. In the more formal
setting of cyber-counseling, intake information would provide basic information if the


35
anywhere. This is an unsettled area, so it is smart to take a conservative approach until
further guidelines are developed. She advised, generally speaking, unless there is a
specific disclaimer in the insurance policy, the carrier would have difficulty denying
coverage for malpractice claims for work within the scope of mental health treatment by
a licensed psychiatrist. Therefore, a licensed professional may be covered for liability
while practicing on the Internet but geographic scope of practice area is a concern.
Grohol however points out, sadly, that licensing boards are infamously inactive in
pursuing complaints and taking action against licensed professions. His advice is to
practice within professional ethical guidelines and within ones expertise and let case law
evolve (Grohol 1999a).
Modalities
T elehealth/T elemedicine
The American government and military interest in the Internet included all
aspects of defense including the health and care of personnel in remote areas.
Telehealth/ Telemedicine is the branch of Internet use and research that provides
electronic healthcare to military and civilian populations who lack readily available
geographic access to medical care.
E-mail
Therapy via e-mail is currently the most widely used form of Internet mental
health service outside Telehealth/Telemedicine, and the most accessible to clients and
therapists. E-mail was an after thought of Internet developers who found it convenient to
communicate with one another involved in a complex project design. It requires minimal
bandwidth and can be accessed with an appliance for those who cannot afford a
computer. E-mail service can be obtained from several free sources.


45
responsibilities. No one denies that these technologies are cumbersome and may well
cause therapists to think twice about practicing on the Internet or incline some therapists
to practice without adequate safety precautions.
Advantages of Internet Counseling
The perceived advantages of Internet Counseling are its immediacy, availability,
anonymity, and economics (Brown & Walz 2000, Fink 1999, Grohol 1999b, Grohol
2001, King & Moreggi 1998, Patterson 2000, Stubbs 2000). Internet access is
immediate, any day of the week, any time of day, any where in the world. One does not
have to wait for business hours or for an appointment. The Internet users in search of
information, companionship, and advice to get through a sleepless night, pain, or spasms
can readily find help in a chat room, bulletin board or informative web site. The Internet
is available in many remote geographic areas where users do not have access to
therapists. It is available to situationally remote users include home bound care-givers,
the elderly, persons with disabilities, and those who would be at employment or social
risk from seeking counseling. The Internet can be anonymous. Personal information
(age, gender, ethnicity, physical condition) can be disguised. Web counseling is
considerably less expensive than traditional face-to-face counseling. The overhead of
maintaining a web counseling site is much less than that of renting office space,
maintaining a staff, occupational license, furniture and equipment, the myriad of taxes,
and other cost of doing business in the traditional setting. Owners of the PsychOptions
site http://www.psychoptions.com/raters & types of services.htm, for example, lists
the following charges: One question/one problem $25; One e-consultation/first on-going
session $50; On-going session $35; Telephone session $50 for 50 minutes. The one
question, e-consultation and on going sessions are all conducted by email. The


69
This information was collected in personal interviews with the facilitators after they had
completed their all of their sessions with participants.
Application in this Study
The goal of this study is to contribute meaningful research to under-gird and
advise the developing phenomena of Internet counseling. The foundation for good
counseling has been developed over the past century and for good communication over
the past many millennia. The advent of a new venue for communication and the
willingness of mental health professional to move out into this venue should surprise no
one. As counselors boldly go where no one has gone before providing mental health
services in cyberspace, research asks What is known about the new environment? What
needs to be known? What risks can be anticipated? What risks cannot be anticipated?
What known tools can be used as is? What needs to be retooled? What new tools need
to be invented? No one study begin to answers do all that, of course. The purpose of
existing professional literature is to suggest answers or directions to answers for some of
these questions.
It seems clear from the literature that a rich very human culture has developed on
the Internet over the past 30 years, initiated by graduate students at MIT, Stanford and 7
other prominent universities, who were given carte blanc to see what could be done
with the new technology. Government initiates to provide health care to citizens in
geographically remote areas and the commercial emergence of Internet use have paved
the way for cyber-counseling. Cyber counseling appears to lend itself to brief therapy
with non-crisis clients. Several years of cyber counseling practice have created a need
for research to determine the efficacy of cyber counseling and to suggest predictive
criteria for screening potential clients for appropriateness for cyber counseling. Many



PAGE 1

PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING By MARTHALANABOGARDUSGROBLE A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2002

PAGE 2

Copyright 2002 By Martha Lana Bogardus Groble

PAGE 3

DEDICATION This study is dedicated to the memory of George A. Bogardus 1920-2001 Martha Lucille Clark Bogardus 1920-1975 Potato and beef farmers who recited epic poetry at our dinner table insisted that we attend school even when the crops needed harvested instilled a profound love of learning in their children and kept the house filled with books

PAGE 4

ACKNOWLEDGMENTS I wish to express my gratitude to my doctoral committee, James Archer, Jr., Harry Daniels, David Miller and Linda Shaw who permitted me to develop research in a fast-growing and little-researched aspect of counseling Doug Johnson, the WebCT system administrator was an invaluable resource, problem solver, and unexpected source of encouragement. James Watson and Alan Pappas provided access and administrative support at Santa Fe Community College. Robert E Groble M.D. provided the financial backing for this project and granted me leave from office duties to complete it. Kristopher Groble, Loren Groble, and Samuel McFadden interfaced with the facilitators to make their work easier They ran errands, and provided data entry, proofreading, and other computer, management, and clerical services I want to thank the graduate students who facilitated this experiment. Without them, I could not have completed project of this magnitude Daniel Pekich, rehabilitation counseling, and Heather Mc Williams, mental health counseling each worked with a large number of participants and headed the team of facilitators at the University of Florida and Santa Fe Community College respectively. Lakisha Scott, rehabilitation and mental health counseling ; Lamandra Jenkins school counseling; Anjanette Todd, school counseling; Wendy Marsh, rehabilitation counseling; Angela Falcone, mental health counseling; and Lesley LeBaron, marriage and family counseling were seriously committed to the students they facilitated and were dedicated to working with a protocol and theory that might not have matched their own preference They brought a broad IV

PAGE 5

range of counselor training personal interest and racial diversity to the performance of this research I appreciate the instructors who permitted me to use precious class time to recruit participants and who in most cases supported my effort by providing the added incentive of extra credit to their students Laura McCarthy Dawn Snipes Michelle Murphy Kitty Fallon, Natalie Arce Kim Fugate David Marshall Keith Carodine Alan Pappas Michael Smith, Joyce Orr and Paul Stem I would be remiss if I did not acknowledge all of the participants who shared issues that were sincere and intimate to them with their facilitators so that we could learn more about the counseling process and outcome in cyberspace V

PAGE 6

TABLE OF CONTENTS Page DEDICATION ........... ... ... ... .......................... .. .. .. .. .. .... .. .... .. .. ..... ................... .. . .. .. .iii ACKNOWLEDGMENTS .. ..... .. ..... ................. ............... .. .. .. . .. .... .. .......... ................. iv ABSTRACT ....... ..... ... .. ................................................ .. .. .... .. .. .. .. . .. ......... ..... .. ..... .. x CHAPTER 1 INTRODUCTION .................................................................. .... ................................. 1 Scope of the Problem .. .... .......... .. .... ....... .. .. . .. .. . .. .. .. .. . .. .. ...... ..... . ... ........... ....... 7 Theoretical Framework .... .................... ............ .. .. . .. .. .. . .................. .. .............. .. ...... 9 Statement of the Problem ....................... .. . ...... ......................... .............................. 14 Purpose of the Study .. .. .................................................................... .. ....................... 15 Need for the Study ... ................ .. ............... .. ........ .................................................... 15 Rationale for the Study ........ .......................... ....................... .. ............................... .. 16 Research Questions ............................ .............. .. ... ... ... . ........................................ 17 Definition of Terms .......................... .. ......... ... .... ........ .. .. . .. .. .. .. ..... .. .. .... . .. .. .. . 17 Counseling terms ..... .. .. .. . .. .. . .... .. .. ............ ............................................... ..... . 17 Computer Terms .. . .. .. . .. .. . .. .. . .. .... .. ............ .. ....... ..... .. ....................................... 18 Organization of the Study .. ........... .. .... .. . ....... .. ................... .. .. .. . .. .. .... ................... 20 2 REVIEW OF LITERATURE .......................... .. ... .... ... .. ... ... ......... ............ ............ 21 Internet Counseling Basic Constructs ............................ ........................................... 21 Social Presence .. .... .. .. . .. .. .. ............... ............ .. . ....................................... .. .... 22 Mutual trust or trustworthiness .. ... ... ... .... . ... . .. .. .. .. . ... ............... ................. ..... 28 Internet Counseling Issues ................................................................................ ........ 29 Website Security ..... .... ............. .. .. ................ . ...... .......... .. .. .. .. . .. .. .. ... . ...... 29 Legal Considerations ................... .................... .. ........................... .. .... .. . . ... ...... 34 Modalities .. .. . ............ ........... ..... .. ........... .. ................ ............. ..................... 3 5 Telehealth/Telemedicine .................. .... .. .. . .. .. ..... .. .... .. .... .. .. .. ................. 35 E-mail .. .... .......................... .. .. .................. .. .. . ... ...................... .. .. ........ .... 35 Chat/Conferencing .. .. .. . ........ .. .. ................. ................. .. .. .. .............. ...... .. 36 Multi-modal .... .. .... .. ... .. .. ....... ... .. .. . ......... . ....... ........ .............. ..... ............. 39 Unidirectional Information Only .......... .. .. . .. .. .......... .. .. .. . .. .. ............. .. .. . 40 Guidelines for Ethical Practice of Internet Counseling ...... .... .. .. .. .. .......... .. .. .. .. .. .. 40 VI

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Credential Validating Referral Sites .. ................ ...... .............. ........... .................. 41 Advantages of Internet Counseling ..... . . . . ...................................... .............. .. 45 Disadvantages of Internet Counseling ............................................ ..... . .... ... ..... 46 Cognitive Behavioral Counseling Models ........... .. ....... .. ..... ..................................... 48 Cognitive Behavior Therapy ... .. ........... .. .. .. .................... .. ...... .... .. . .. .. ........... . .. 49 Brief Cognitive Behavior Therapy ....... .... .. ..... .............. ....... ..... .. . .................... 51 Using Brief Therapy with Undergraduates ....... ... . . .... .. ..... .. .. .................................. 53 Undergraduate Personal Growth Concerns . ..... .. .. . ........ .. .. .............................. 55 Individual Information Processing Differences ..... ... ........... .. ................................... 56 Demographic Factors ... ....... ... .. .. .. ... ... .... ... .. . ................................................. 56 Leaming Style Theory .. ...... . .. .... .. ........ .. ..................... ... ............ ..... ..... ......... 56 Academic Learning Styles ....... .. ........ .... ... ... ... ... .. ....... ................ ..... ........... 57 Temperament Leaming Styles . .......... ... .... ..... .. .. . .................................... . 59 Leaming Style Conceptualization Comparison ...... ..... .................................. 60 Measuring Information Processing ............................. ...... ....... ................... 60 Personality Attitudes . .. .. .. .. ..... .... .... ................................ ..... . .. ...................... 62 Measuring personality attitudes ... ......... . ... ................................................. 63 Counseling Process and Outcome .. .. ..... ................ .. .. .............................................. 64 Working Alliance ............................... ... . ... .................................. ............ 65 Measuring Therapy Outcome ................... ................................... .. .... ......... 66 Application in this Study ........................................................................................... 69 3 METHODOLOGY .......................... . .... ... ... .. .. .... ............ . ... ....... .... .. .................... 71 Statement of Purpose ....... ........ .... ..... .. ............. ....... ......... ........... . ........................ 71 Hypotheses .. ........ . ..... ............. ... . ... ......... ... .. .. ..... .. .... ........................................... 71 Descriptions of Variables ....... ... ....... ..... ... .............. .. .......................... .... .. .. .. ..... . 73 Dependent Variables ......... ................... .... .. .. ..... . .. .. .. ....... .......... .. .. .......... ...... .. 74 Independent Variables ......... . . ....................... .. ................................................. 74 Population . ........ ... .. . .. ..... .. .. ... .......................................... ... .. .. . .. .. . .. .. ..... .. .. .. .. 75 Sampling Procedures .. ...... ......... . ............. ... ... .. .. . .. .. ... ......... . .... ..... ... ...... ............ 76 Data Collection Procedures ............ ................. ..... .. .. ..... .. .... ... .. . .... .. .................... 77 Instrumentation . . .... . ..... .. .. .... .. .................... .............. .. .... .... . ..... .. ..... ..... . .. ....... 79 Working Alliance Inventory (Client) .. .. ............................................................. 79 Working Alliance Inventory (Therapist) ........................ .. .. .. .... .............. .. ..... .. 80 Outcome Satisfaction Questionnaire .. ........................... ..................................... 80 Myers Briggs Type Indicator Form M (MBTI) .................................................... 81 Center for Innovating Teaching Experiences Leaming Styles Inventory (CITE) .. 83 Demographics ............ ..... ........... .. ....... ..... ..... ................................................... 84 Data Analyses Procedures .. .. .. .............. .. .. . ............................................................ 84 4 DATA ANALYSIS ................. .. ................ ..... ... ... ..... ..... . ..... ..... ..... ............ .. 85 Descriptive Statistics for Dependent Measures .......... ......................... ............... 85 vu

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Participant Dependen t Variables Analysis .. ........................... ................................. 86 Predicted future use (participant) .......... . ... .................. ..... ................................ 88 Le v el of Compu t er/Internet Skill ........................ ................ .. ..... ....................... 90 Outcome Sa t isfaction (Participant) ... .. .............. .. ............. ................................. 91 Working Alliance Inventory Total (Client) ........... .. ........... ................. ............. 92 Working Alliance Inventory Bond (Client) .............. .. .. .......................... .......... 93 Working Al li ance Inventory Task (Client) .................... ..................................... 93 Working All i ance Inven t ory Goal(Client) ................................... ....................... 95 Fac i litator Dependen t Variable Analysis .. ........... ..................................................... 95 Outcome Satisfaction Questionnaire ................................ ................................... 96 Working Alliance Inventory Total (therapist) ... .............. ... ............................... 97 Working Alliance Inventory Bond (therapist) ...................................................... 98 Working Al li ance Inventory Task (therapist) ....................................................... 99 Working Alliance Inventory Goal (therapist) .............................. ... .................. 101 Qualitati v e Analysis .......... .............. ............................. .................................. 103 5 SUMMARY CONCLUSIONS AND IMPLICA T IONS ......................................... 106 Summary o f t he Study .............................. . ............................................................ 106 L im i tations ........................................................... ............................................ ..... 1 08 Implications and Recommendations ....... .............. ....... .......................................... 110 Research ...... ................................................................... ................................ 110 Cl i nical ....... ............ ............ ...... ................................ .. ................................ 111 APPENDICES A FORMS AND IN STRUME NT S ..... ............... ....................................................... 1 14 Participan t Contact Sheet ............... ........... .................................... 114 Informed Consent .... ....... .... ....................................................... 115 Outcome Sa t isfaction Questionnaire ............ ...................................... 117 B FACILITATOR TRAINING MANUAL . ........ .............. ............... ...................... 1 20 Table of Conten ts ................................... . ....... ...................................................... 1 20 Logist i cs ................................................................................................................. 1 21 Sess i on Structur e Guidelines .................. .... .... ... ........... ...................................... 1 24 Therapy Plan and Progress Notes ............... ............................................................. 127 Facilitator Chec kl ist. ...................... ......................................................................... 128 Sample of tracking sheet ................... ............ ............... ................. ....................... 1 29 WebCT samples screens ................... ....................... .. .. . .. .. .. . .... ........................ 130 Required Reading Study Protocol .............. ..................... . . ......... .. .............. ....... 132 Required Reading College Student Counseling ..................... .. ............................... 133 Vlll

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C COMPUTER-MEDIATED SESSION TRANSCRIPT ................... ........................ 134 LIST OF REFERENCES .... ..... .... ........ .. .... .... ........ ....... .......... ................................... 144 BIOGRAPFIICAL SKETCH .......................................................... ............................ 160 IX

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING By Martha Lana Bogardus Groble December 2002 Chair : James Archer Jr. Department: Counselor Education This study examined the process and outcome efficacy of Internet counseling by comparing it to traditional face-to-face counseling in an experimental environment. We recruited 123 undergraduates from fourteen classes in two institutions of higher education Students volunteered to participate in three personal growth sessions and complete five surveys. Ten graduate students were trained to conduct brief cognitive behavior therapy in personal growth sessions within the research protocol. Facilitators were trained to use the chat room and survey functions of the University's secure remote classroom system WebCT. Participants were randomly assigned to the face-to-face or computer-mediated condition Facilitators conducted an equal number of sets in each condition but each participant was seen in only one of the two conditions. The demographic survey was conducted in the classroom during recruitment while the other four surveys were completed after the last of the three personal growth sessions in the WebCT survey site, whether the participant had been assigned to the face-to-face or computer-mediated condition. Facilitators completed two surveys after each set of sessions. X

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Process efficacy was measured with the Working Alliance Inventory (WAI) forms client and therapist The WAI provides a score for total alliance and sub-scores for bond task, and goal key factors in the development of a therapeutic milieu Outcome efficacy was measured with a researcher developed Outcome Satisfaction Questionnaire with three scales outcome satisfaction, computer skill level and prediction of likelihood of future use of computer-mediated counseling. The independent demographic variables age ethnicity and gender were collected from the contact information form completed during recruitment. Learning style preference was determined using the C.I T.E Learning Styles Inventory and the Meyers Briggs Type Indicator (MBTI) Personality attitude preference introversion or extraversion was determined using the MBTI Significant main effects were found for the academic learning style systems and for gender. Significant interactions were found for gender by condition indicating that males reported greater process ability in the face-to-face condition contrary to a stud y hypothesis No significant results were found for age, ethnicity introversion/ extraversion or research condition. Recommendations for further research and clinical applications are discussed XI

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CHAPTER 1 INTRODUCTION At the dawn of the 20 th century the fledgling professions of psychiatry psychology and counseling were beginning As the 21 st century begins a radically different service delivery method which may in fact generate a radically new helping profession, is occurring The current world population of Internet users is estimated to be around 349 million and growing (Stubbs 2000) A segment of these users are accessing mental health services variously known as Telecommunications Telehealth, and Telemedicine Telecontact between a mental health provider and a mental health consumer may simply be a plain old phone call to reassure a patient that his or her medication has been called into the pharmacy ; a copy of an e-mail of a typical interaction with a troublesome relative which records the transactions while they are fresh, for processing in the next scheduled therapy session ; peer moderated bulletin board support groups ; video conferencing to train parents how to care for children with seizure disorders ; live interactive Internet dream work with a renowned dream therapist ; or a very complex, surrealistic virtual reality counseling world Computer-mediated counseling is in its infancy However the generic and programming code necessary to bring it to maturity is already in place for interactive graphic (sound visual and animated) virtual worlds where clients can choose avatars or symbols to represent themselves and to characterize the psychotherapy issues salient to their needs 1

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2 Although the technology and evolution of virtual reality are 30 years old its application in counseling has not yet been significantly engaged The virtual counseling world is the quintessential postmodern constructionist therapy environment. Fink (1999 pp 28-29) reasoned computer-mediated communication (CMC) clearly a postmodern phenomenon, are a form identified by the mediator (the computer) as well as by the communicator (the virtual ego) The machine determines existence .... (u)sing present technology CMC tends to be fluid cycling and devoid of social cues which constitute modernity Accordingly psychotherapy that uses CMC is also amorphous shifting in response to context technology and the nature of patient interaction ." In essence the counselor and client co-create the cyber counseling experience in the material processed behavioral issues distorted thoughts troubling problems faulty cognitions overwhelming emotions and in the very essence each participant chooses to contribute to the structure of the working space. Language spoken or written, forms the connection between two people Stanley (2001) argued that rather than language being a reflection or mirror of social life language itself constructs social life when it is practiced Discourses produce different versions of this social life different realities The goal of discourse analysis then is not to improve upon people s accounts but rather to understand how they are practically achieved ." Much of the power differential between client and counselor dissipates when each presents without the hallmarks of embodied age race gender physical attractiveness size and shape native language dialect speech impediments, or peculiar mannerisms which color and may distort face-to-face communication with preconceived stereotypes and subtle biases For example the researcher had a revealing chat experience with an

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3 American living in Iceland This was a personal recreational activity not a professional relationship While both were using an AOL Dream chat channel the person in Iceland popped-in" to the researcher s screen via the private channel (instant messenger) when the researcher mentioned that she lived in Jacksonville Florida The person in Iceland had moved from Jacksonville Naval Air Station to the Iceland Naval Air Station and was lonely The researcher was familiar with both geographic locations both Naval Air Stations and with military-family life. The researcher assumed that the person with whom she was chatting was a young wife of an enlisted sailor The chat contents were volcanoes glaciers lava beds hot water lagoons things to do in Reykjavik, Icelandic mythology other exotic locations familiar to both The researcher terminated the interaction when she learned that her cyber-friend was a 12-year-old girl. Nothing had ever been discussed that was inappropriate when talking with a child Nothing had ever been discussed that the researcher had not discussed with hundreds of children that age during her career as a natural history museum curator ; however, a personal bias of how or when or for what reasons one related to a child had been violated (a surprising revelation to the researcher) The girl in Iceland had never claimed to be anything other than what she was a situationally lonely and resourceful kid who moved all too frequently to become rooted in any conventional community a person regardless of age who was interested in relationship friendship computer communication and natural history One would think that age should not matter in this situation but it did Most saliently it is precisely for this population (the geographically isolated) that telehealth, telemedicine and cyber-counseling are most strongly advocated. In the more formal setting of cyber-counseling, intake information would provide basic information if the

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4 client chose to respond accurately However, in virtual reality one can role play age, race gender, physical attributes and try on a vast range of solutions from which to select practical ideas to apply in his or her social-gravity bound life The counselor in virtual sessions will not only be aware that the client may be role-playing but will need to develop new theory which promotes and capitalizes on a therapeutic world free from factors that often may actually be the source of the clients' distress. This radical new formulation of therapy may be analogous in the physical sciences to work done in space in the absence of gravity Obviously one does not live long in the absence of gravity without serious physical consequences (e g loss of bone mass and tissue density). However, as a special condition to accomplish a specific end ( e g., re-growing tissue more quickly and with less pain) it has therapeutic advantages heretofore unavailable in theory or in practice. The powerful value of such study is clearly demonstrated by a global community's willingness to engaged in the high risk, construction of our third multibillion-dollar facility for such research the International Space Station (preceded by Skylab and Mir) Cyber counseling therapy in the absence of the weight and pressure of social markers allows a healing space not a long-term residence for the client. Just as NASA researchers and their Russian counterparts must experiment and learn about the weightless environment available in near outer space mental health researchers must experiment and learn about the social and relational weightlessness of cyberspace Cyberspace then presents the constructionist need for a completely new theory of counseling, a completely new way of thinking about counseling, not just a new delivery system.

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5 Entering cyberspace then, disembodies the counselor and the client In therapy in cyberspace the nature of the interaction first deconstructs the everyday givens of the counselor and client, then the two co-construct a new healing reality through the therapeutic dialogue Is that not the crux of psychotherapy helping guiding, facilitating and coaching clients to discover learn, or experience their story, their inner dialogue in a new more self sustaining way? The major mental health professional organizations (National Board of Certified Counselors American Counseling Association, American Psychiatric Association, American Medical Information Association, American Psychological Association, Commission on Rehabilitation Counselor Certification) agree that now in the infancy of Internet counseling is the time to set the values ethics and discipline ofthis new opportunity (NBCC 1997 NBCC 2001 APA 1997 AMIA 1998 ACA 1999 APA 2001 CRCC 2002). Virtual Psychotherapy will have as little in common with the theory context content and outcome of contemporary psychotherapy as contemporary psychotherapy has with priests and shamans In the pre-modem or pre-science era, priests and shamans healed physical emotional and spiritual distress based on observations and beliefs about the natural and supernatural world using plant materials astronomical observations beliefs about supernatural interventions and such In the 1990s and 2000s these ceremonies continue but it is unlikely that Blue Cross Blue Shield or any other third party payer would assume financial responsibility for a Sufi whirling dervish, a Greek Orthodox exorcism a Pentecostal spiritual slaying an Episcopalian laying on of hands healing service a Sunni (Lapland) sweat lodge, a Kiowa medicine wheel a Lakota buffalo hide ceremony Saginaw Chippewa eagle feature ceremony yogi fire walking

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6 treatment or a Huichol peyote ceremony even though these practices are far more ancient and continuous than modern psychology and have anecdotal efficacy (which, admittedly is difficult to quantify). In the modern era of scientific understanding and explanations physical illness and emotional distress have been dichotomized and spiritual meaning has been severed from the treatment arena Postmodern disappointment with the limitations of science has revisited issues of holistic medicine prayer faith, sympathetic magic (e g. crystals), imitative magic (e.g ., smoke feathers) and worldview in the relief of distress The same is projected for the postmodern era and cyber counseling Notably all pre-modern and modern treatments recognize the value of a helping relationship between the helper and the person seeking help and a satisfactory outcome. The outcome must be satisfactory in many or most cases or the method would have become extinct or at least superceded by major reformulation (e g ., trepanning to high technology brain surgery leaches to lancing) Disembodied asynchronous and globally accessible therapeutic models will expand the limits of thought and theory about the necessary and sufficient conditions of therapy and the nature of therapy Language and overt self expression have always been the working matter of counseling i e ., Freud s talking curehowever, language and imagination will predominate in cyber counseling and will require new conceptualizations of the essence of language in a polyglot world community (Shotter 1993). The language of the Internet is English American English (Fink 1999) English is the lingua franca of commerce and science. Internet therapy were influenced limited and contaminated for clients whose native language is not English even though they may

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7 have learned English in a country or culture that places high value on knowing English and teaches it beginning in first grade English as a second language has been identified as a multicultural issue in counseling. How much greater will this issue become in a global environment ? Counseling laws where they exist tend to confine counseling to the state of the therapist's licensure ; however there are no International constraints A potential client can be asked to affirm that she or he lives in the state of the therapist s licensure However that does not mean that the person does or if he or she does that he or she lives in an acculturated community If a person s English or Spanish appears to be adequate to the counseling demands can we assume that the person is keying in his or her comments directly through the computer or is the client talking to a typist who enters the comments or to a translator who must interpret both sides of the communication inadvertently and subtly changing each side. Web cam technology offers some solutions or hope for solutions to the disembodied and perhaps linguistic problems posed in Internet counseling An area of counseling is likely to evolve in the virtual reality model that is independent of physical and verbal cues Virtual real i ty models and virtual reality role playing have 30 years of history and refinement from the worlds of virtual gaming and virtual socializing Fundamental issues of human presences viability efficacy, ethics limitations indications contraindications, national and international licensing and liability and risks to clients must be thoughtfully discussed debated and researched Scope of the Problem Psychotherapists are using the Internet to provide a full range of mental health services Powell (1998) surveyed licensed Internet counselors listed on the Metanoia

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8 website She learned that the 13 respondents served 445 clients in 1995, 947 clients in 1996 and 1344 clients in 1997 Over 15 000 health care related web sites were reported in 2000 (Dunaway 2000) While many of these are telehealth and referral, if only 5% are counseling and therapy sites and if 1997 statistics are applied to that 5% nearly 100 000 clients are presently receiving mental health services via the Internet in the absence of empirical data to support the efficacy of this service Of Powell s respondents 85% primarily used email for their Internet service; however 33% of these counselors had chat capability and none were using virtual reality technology These figures do not include peer-moderated electronic bulletin board peer-moderated chat rooms and private messages Counseling issues included relationship issues, depression, family issues substance abuse and anxiety (Powell 1998) In 2001 the organizers of the HealthyPlace com website both list and recruit mental health professions, creating a network of referrals and some measure of credential verification Members are encouraged to provide supervised web sites called communities in the areas of abuse ; ADDI ADHD; addictions ; alternative mental health ; anxiety and panic disorder ; bipolar disorder ; chronic pain ; depression ; dieting ; eating disorders; gay, lesbian and transgender issues ; obsessive-compulsive disorder ; parenting ; personality disorders ; relationship ; self injury ; and sex/sexuality "Partners are encouraged to manage a complete website write a topic specific column be the community s "ask-a-doc columnist maintain a journal/diary manage an e-zine or write an Internet newsletter Holmes (2001) whose screening appears to be more selective has links to over 700 counseling sites The owners

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9 of Psychnet com sell mental health related domain and the tools to develop them at http://www psychnet com Concerned professionals began researching the Internet services, even before the Internet became available to the public in 1994 (Colon 1994). Professional organizations have been debating salient issues (Holmes 1997). The federal government has passed a telehealth bill (U.S. Congress 1997, HCFA, 1996, HCFA, 1999). In 1997 the state of California enacted the first state law restricting California therapists to in-state Internet clients (Maheu 2001) The American Counseling Association researched current practice in distance learning related to mental health and cyber counseling A major recommendation from that study was the need for research in the area of cyber counseling (Brown & Walz 2000) Cyber counseling research must build the theoretical foundation and constructs of Internet communication and of mental health counseling. Theoretical Framework The theoretic framework for this study consists of the constructs of social presence, (Lombard 1997, Reid, 1994), trustworthiness (Edwards 2000) and intimacy (Robson 1998) in cyberspace, counseling in cyberspace, person centered alliance building skills, brief counseling, learning styles, and personality traits "Psychotherapy is a human relationship that heals" (Suler 1999) For a relationship to develop both participants must be involved in a personal, dynamic manner. Earliest theories of the Internet as simply an impersonal source of information were quickly replaced by the information foraging cognitive model (Priolli 1999), the sociological "gathering and communicating model" (Sproull 1997) and the anthropological expanding human experience : understanding artifacts, and culture model (Mantovani 2001) to better reflect the evolution of Internet use and the experience of Internet users. The Social Presence Theory is a micro theory

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10 that identifies six components of social presence, a prerequisite to interpersonal relationship on the Internet and, therefore, a prerequisite to Internet counseling -social warmness, realism, transportation "you are there," "we are there," perceptual and psychological immersion, social actor within the medium, and medium as social actor (Lombard 1997) Almost all counseling theories emphasize the importance of the interpersonal relationsfilp between the counselor and the clients, although they may vary in the manner in which they deal with the helping relationship, transference, counter transference, or working alliance. It is reasonable then to infer that social presence is a key concept for the development and evaluation of Internet counseling It should be noted that several projects have attempted to create computer-as-counselor (Wizenbaum 1966 Maes 1995, Ookita, 2001) However, this study examines the human counselor client interaction with computer as communication mediator. Computer-mediated communications is not, in and of itself, psychotherapy, no matter how personal, rewarding, helpful and satisfying it may be Hampton and Houser emphasized that "the Internet is a tool and it has no more inherent ability to cause harm than a telephone. Like other tools, if we use it properly, it will be helpful and beneficial However, if we misuse it, the consequences will be detrimental (Hampton 2000) ." A century of research and application have demonstrated that psychotherapy is a particular form of communication supported by heuristic theory, discrete techniques, and demonstrable outcome results. Now research must do the same for computer-mediated communication so that Internet counseling will be helpful and beneficial rather than detrimental. This study was designed to contribute to that needed body of research To do so, the study compared brief cognitive behavioral theory applied in personal growth

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11 session s used in two conditions face-to-face or computer-mediated sessions Cognitive behavioral theory defines and describes salient constructs as cognitive events cognit i ve processes and cognitive structures (Meichenbaum 1988 Meichenbaum 2000) Cognitive events are conscious identifiable or readily retrieved thoughts images and accompanying feelings These events include internal dialogue expectations espoused beliefs and appraisals Cognitive events occur when the person's automatic behavio r is interrupted when one is uncertain about making a choice or judgment when one is troubleshooting and when one is exercising recall or reconstruction of an event or idea Cognitive processes are defined as the way a person processes information These processes include information storage search, retrieval and application Cognitive theory suggests that information is received encoded stored retrieved and applied to a given situation based on the beliefs and values of the individual. That is not all possible information, which one encounters is stored or retrieved There is a selection process based on salient beliefs and values An artist, for example may store shape form, color light and texture information extant in the everyday world which others would miss entirely The artist can retrieve that information in another setting because it is relevant to his or her worldview. At least three of these cognitive processes confirmatory bias mental heuristics and meta-cognition, are important in psychotherapy Confirmatory bias is a process by which the person stores and retrieves information that confirms a belief or value without questioning the underlying belief Using this process the individual filters out any contrary information or ambiguous information, denying that individual necessary information in the current situation Mental heuristics are processes or templates for making decisions in ambiguous situations Stereotyping is a common

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12 mental heuristic Meta-cognitions are ways of thinking about and controlling cognit i ve processes Scarlett O Hara s tomorrow is another day or little orphan Annie s the sun will come out tomorrow are meta-cognitions, cognitive processes or templates that automatically inform that believer to ignore today s disappointments fears worries and concerns because they were gone tomorrow. Cognitive structures or schemes are templates that are pervasive readily accessible, and reflect personal themes Each theory of psychotherapy has generated techniques or procedures that use operationalize and/or apply the theory in concrete situations with particular clients Beck and his colleagues (Beck 1979) emphasized that cognitive behavioral therapy is collaborative work, which begins with rapport To develop this working relationship they recommend that a good base for building of rapport is simple courtesy not keeping the patient waiting remembering important facts about him and giving a sincerely warm (but not effusive) greeting Maintaining eye contact following the content of the patient s talk, trying to infer and reflect the patient s feelings and phrasing questions and comments diplomatically help to build rapport The choice of words and labels is important (p 53) For example non-productive ideas is preferable to neurotic ," sick, or irrational thinking The working relationship in cogniti v e behavior therapy however is more than rapport building which can be accomplished in a hierarchical relationship as well as in a collaborative relationship In a cognitive behavior therapeutic relationship the therapist and patient work together to determine how and what the patient thinks the basis for such thinking and the practical benefits and losses that result from such thinking The patient's unique contribution to this collaborative effort is to provide the raw data for this inquiry that is to report his

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13 thoughts feelings hopes dreams and wishes The therapist s special contribution is t o guide the patient about what data to collect and how to utilize these data therapeutically (p 54) Other collaborative techniques include authenticating introspective data "," investigating underlying assumptions ," setting up experiments ", and homework assignments all of which are conceptualized as making the client his or her own folk scientist whose research is focused on his or her own best interest personal problem solving and successful living The process of therapy and the outcome satisfaction as reported by both the participant and the facilitator were evaluated to determine the efficacy of computer mediated counseling A therapy outcome is related to both what happens during the therapeutic process and what the participants bring to the process This study examined cultural factors and personality traits that the client brings to the therapeutic process gender ethnicity learning style and personality traits Learning style theory an operational application of information processing research, is an important construct that identifies inherent learning strength and examines differential sensory and social ways in that people prefer to learn and learn most successfully (Babich 1976) Personality traits or the hard wiring of individual differences in attitude response to the stimuli collection of information from the world and source of energy and authority were simultaneously suggested by Jung and by the mother daughter team, Myers and Briggs Myers and Briggs (Myers 1962) operationalized Jung s theory in the Myers Briggs Type Indicator (MBTI) Of particular interest in this study is the introversion/extroversion scale because Reid (1994) and Fink (1999) each suggested that computer-mediated communication favors those with an introverted attitude Jungians

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14 have researched temperaments and their contribution to the manner in which people prefer to learn either in a formal educational setting or in life in general. This more pervasive learning style was examined as well as the academic specific learning style developed by the Wichita Public School System. Computer-mediated communication, computer-mediated social presence cognitive events, cognitive processes cognitive schemas learning style personality type and working alliance are the major constructs that form the theoretical foundation of this study Statement of the Problem It has long been the sin qua non of the helping professions to Do No Harm Clients seek counseling because they perceive it offers hope, help assistance and guidance in a time of confusion, pain, loneliness or danger. Professional and governmental agents exist to assure clients that the professional from whom they seek help is trained qualified and practicing in a safe and proven manner Insurance companies and other third party payers often refuse to reimburse any treatment that is considered unproven or experimental. When new methods are developed they must be reproducible and scrutinized by the professional community to insure that they are safe and effective It cannot be assumed that when there is major change in the manner in a service is provided the therapy is identical to previously validated methods. Internet counseling must meet the same standard of applicability and efficacy that is required of all other modes and forms of counseling Research must inform clinicians regarding appropriate selection of clients who are likely to benefit from Internet counseling and must demonstrate useful theory and techniques in the cyberspace-counseling environment. One size does not fit all and one technology certainly does not fit all.

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15 Purpose of the Study The purpose of this study was to compare and contrast the development of working alliance (Horvath 1993 Horvath & Greenberg 1986, Horvath & Mars 1991 Horvath & Symond 1991 ) and outcome satisfaction with traditional face-to-face brief group counseling and with computer-mediated brief group counseling The effects of learning style (Babich 1976) and personality traits were analyzed to determine if potential differential efficacy of face-to-face or computer-mediated counseling could be predicted The study will examine which, if any specific learning style and personality traits are predictive of success in one modality or the other Need for the Study Few studies exist to guide psychotherapists who decide to move all or part of their practice to the Internet. Most of these studies are surveys and other qualitative studies as is appropriate for developing heuristic for a new area of inquiry (Barak 1999 Colon 1994 Dunaway 2000 Fink 1999 Harris-Bowsbey 2000 Stubbs 2000) Virtual Reality (VR) the high end of Internet technology is being studied with statistical rigor in the treatment of phobias (North 1994 Rothbaum 1997) cardiac illness in children (Bers 1997) and chronic pain at a bum clinic (Patterson & Hoffman 2000) Ethics working papers and guidelines exists to structure Internet psychotherapy (NBCC 1997 ACA 1999 AMIA 1998 APA 1997 Brown & Walz 2000 Holmes 1997 NBCC 2000 CRCC 2001) and there is no dearth of technology and technical assistance to develop and market Internet therapy There is however a critical need for empirical research to analyze typical Internet therapy after almost a decade of development. The primary therapeutic use of the Internet appears to be Internet support groups (King 1998). Because of this widespread use, the American Psychological Association

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16 conducted an Internet support group symposium at their annual convention Barak and Wander-Schwartz (1999) report one of the only studies of Internet therapy They describe their study as preliminary, warned that its findings should be interpreted with caution and called for intensive research Several professional and scientific questions of relevance include : Is Internet therapy useful beneficial satisfactory and efficacious ? Is Internet therapy harmful? Does Internet therapy immunize potential clients to effective face-to-face treatment? Is Internet therapy a technology placebo? Is Internet therapy snake oil ? Do the personality traits of the client influence the effectiveness of Internet counseling? Is the Internet, as one author suggests revenge of the introvert? Is a visual learning style more conducive to effective Internet results than a verbal learning style? Does the physical isolation of computer-mediated psychotherapy hamper the success for clients with social group learning style preference? These are but a few of the questions that need to be considered especially if the cyber client is to be provided with appropriate services the psychotherapist is to remain in compliance with his or her professional ethics and credentials and if the insurance industry is to recognize and reimburse Internet therapy. Rationale for the Study This work contributes to the foundation for the lower end technology interface It will benefit counselors who wish to work well and ethically Internet. With this and similar research, counselors will have tools to determine which clients are best served by Internet counseling and which clients need to be seen face-to-face It will benefit clients who are geographically or situationally isolated from counseling services to be able to make an informed decision about Internet counseling Since the federal government health benefit program has long supported some forms of telehealth and telemedicine as a

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17 costcontainment means a strong research effort is needed to support the claims of counselors and clients for third-party payment. Research Questions The following six research questions were examined in this study : 1 Is brief, Internet counseling as effective as brief face-to-face counsel i ng? 2 Does working alliance develop equally well in brief, Internet counseling and in face-to-face counseling? 3 Does the information processing style ( visualizing/verbalizing) of a participant influence the effectiveness of Internet brief cognitive counseling? 4 Do personality attitudes (introversion/extroversion) of client affect the efficacy of Internet brief cognitive counseling? 5. Does the ethnicity of the client affect the efficacy of Internet brief counseling? 6 Does the gender of the client affect the efficacy of brief cognitive Internet counseling Definition of Terms Counseling terms Learning style the sensory and social process by which an individual acquires encodes stores and retrieves information, including visual verbal kinesthetic tactile social-individual social-group expressive-oral and expressive-written (Babich 1976) Personality Traits as defined by Jung (1923) these are psychological fiji ctions of thinking feeling sensing and intuiting, which interact with attitudes of introversion and extroversion Myers (1962) added the constructs of judging or perceiving (cf MBTI) Each individual has preferred functions and attitudes that he or she generally prefers to use to collect information about and interacts with his or her intrapersonal and interpersonal environment.

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18 Working Alliance the therapeutic relationship that develops in the counseling environment to facilitate success Three components of the working alliance are the bond between client and counselor, mutual agreement on the goal of therapy, and mutual agreement on the tasks of therapy that will accomplish the goal (Bordin 1976) Computer Terms Synchronous-(antonym asynchronous) means happening at the same time or moving at the same rate of speed or having the same rate and phase as vibrations (Gurainik 1979). These are key concepts in Internet communication and refer to the ability of people to communicate at the same time (synchronous) from any computer in the world or near outer space or to communicate at different times (asynchronous) Examples of synchronous interactions are text chat and media chat. Email and bulletin board discussions are asynchronous. (Suler 1999) Chat real time live, or synchronous text conversation between two or more people located at a computer keyboard anywhere on the planet or in near outer space (Young, 1998) Cyberspacea term coined by science fiction writer William Gibson (1984) to describe the space that exists between people, computers, satellites and phone lines E-mail generally one to one written "letters" but courtesy copies, blind courtesy copies, and group mailing are also common (Young 1998) Encryption applying mathematical algorithm to plain text to produce apparently unintelligible text for security purposes during transmission (Smith 1997) Telehealth/telemedicinedeveloped originally by NASA (2001) in the early 1960's to provide health care and monitoring for astronauts, beginning with Project Mercury It

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19 provides assistance in disaster stricken areas throughout the world and applies space based technology to terrestrial medical care URL the address or location of information on the Internet. The acronym stands for Universal Resource Locator (Young 1998) although Berner-Lee (2000) a particle physicist who created the World Wide Web, originally used URI for Uniform Resource Identification and the terms are often confused because the URI is still used for addresses on the Internet outside the worldwide web. The URL of a popular search engine for example is http :// www google com While most clients will see the URL the direct form is http : /!216.199 19 139/ the URI of a small business in Jacksonville An email address is not a URL or a URI but rather a hyperlink to a section (bin) within the service provider s website Virtual Reality (VR) immersion technology currently being used at MIT and elsewhere to treat pain and phobias VR is a graphic and animation rich computer environment which simulates visual auditory and tactile sensations For microcomputers (PCs and Macs) VR uses MOO (MUD Object Orientation) virtual reality programming code that allows the creation, use and manipulation of items on the screen. MUD is Multi-User Dungeons, (now also Multi-User Domains Multi-User Dimensions) a virtual world originally developed in the 1970s and 1980s for playing adventure role-playing games MUSH is Multi-User Shell a programming system that allows users to develop and manage either an adventure or a social MUD (Bruckman 1995) This technology can potentially be used to develop VR counseling from any computer given adequate bandwidth and baud rate to both the counselor and client computers

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20 Organization of the Study This study consists of five chapters, an abstract, three appendices, and a list of references The abstract and introduction present the Internet and counseling context for the study describing research issues of the growth and professional concerns about Internet counseling The second chapter reviews relevant scholarly literature on social presence, Internet counseling, face-to-face brief counseling, working alliance measures, outcome efficacy measures, learning styles and personality traits The third chapter describes the structure of the study, characteristics of the participants, dependent and independent variables observed, measures used, and statistical procedures applied to analyzing the results of the experiment. Chapter four presents the statistical results and chapter five discusses the significant results, potential impact to Internet counseling, limitations of the study, and recommendations for Internet counseling and further research The appendices contain forms and measures created for this project, protocol for facilitator training and sessions, and a sample computer-mediated session transcript.

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REVIEW OF LITERATIJRE The relevant scholarly literature is reviewed in this chapter Topics to be reviewed are research ; Internet computer counseling concepts ; Cognitive counseling theories ; personality traits ; temperament learning style ; academic learning style and counseling outcome and process theory The exiting Internet research which is primarily qualitative and heuristic addressed the social and cultural dimension of Internet transaction and the construct of social presence on the Internet a prerequisite to counseling The advantages and concerns about Internet counseling as discussed by the mental health professional organizations and activists and current applications of counseling on the Internet. While outcome efficacy of Internet counseling is a concern in all theoretical approaches for the purposes of this study the theory used is brief cognitive behavior therapy Research regarding basic precepts of cognitive behavioral therapy basic precepts of brief therapy and the construct of working alliance are reviewed Relevant research about personality traits theory and application of learning styles are discussed as related to independent variables in this study The theory and instrumentation for evaluating the independent (personality type and information processing style) and dependent (working alliance and outcome) variables are presented This chapter concludes with a discussion of the contribution of the existing research to the formulation of the present study Internet Counseling Basic Constructs To counsel in cyberspace one must first assess the constructs and theories defining human relations in cyberspace. Counseling is a human interaction, which is a 21

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22 good deal more complex than ordering a book from Amazon.com or a rose bush from JacksonandPerkins.com Is there a subjective component to human interaction in cyberspace? Is there a "person" or "psyche" to counsel? Three major concepts have been discussed at length social presence, trustworthiness and intimacy. These factors create an environment in which a therapeutic alliance can be developed One of the three essential components of a therapeutic alliance is the development of a personal bond Social presence, trust, and intimacy or self-disclosure, create the milieu in which a personal bond can develop between the therapist and client. The client and the counselor need to experience a sense of bond, connection, or rapport The bond can be based on the sense of mutual trust liking, understanding and care (Bordin 1976, Horvath & Greenberg 1986) Social Presence. Is there social presence in cyberspace, and if so, how does it manifest? In response to the gamut of pressures emanating from the war in Viet Nam and the Cold War, government military and related universities developed the technology to deliver information around the world and into near outer space almost instantly At the same time, social, political humanitarian and radical thinkers were developing experiments in human living that were just as dramatic The social geniuses of the era readily adapted and defined the ultimate use of the Internet. Rheingold (1994) was perhaps the first social thinker to systematically describe the social and cultural communities that developed on the Internet. The WELL a San Francisco founded, Internet community dating from the early 1980s grew out of the social activism, communal living experiments and democratic philosophies of the 1960s. The personal involvement and

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23 real life connection among members is illustrated in the following two incidents The WELL community organized a massive medical resource location, medicine delivery, and member return transportation from India to San Francisco when a former member who had become a Tibetan nun developed a rare liver condition and was destined to die in India without this heroic, real time, real cash, real resource, unbidden, but greatly appreciated massive intervention (28-32). In another case, a prolific member of the WELL committed Internet suicide, the act of removing all of his years of comments and conversations written into the fabric of the community. Alert members of the community called him, assured that he sought and received professional help, and notified his family and other friends In the end, the effort was insufficient and the member committed real world suicide Rheingold mused "Suicide brings up unusual feelings in any family or social group. Fortunately, there were one or two among us who knew exactly how to understand what was happening to us : a fellow who had struggled with years of feelings over his brother's suicide was able to offer wise and caring and credible counsel to many of us There was a real-life funeral, where we brought our physical bodies and embraced each other and Blair's family We were learning how fond we had grown of Blair, and how his death put a milestone in cyberspace. Marriages had happened and others had unraveled Businesses had started and failed We had parties and picnics But death seems somehow more real, even if your only participation is in the virtual funeral. How could any of us who looked each other in the eye that afternoon in the funeral home deny that the bonds between us were growing into something real? The feelings ran just as high during the virtual part of the grieving rituals as they did during the face-to-face part indeed, with many of the social constraints of proper funeral behavior removed, the Internet version was the occasion for venting of anger that would have been inappropriate in the face-to-face gathering There

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And ... 24 were those who passionately and persistently accused the eulogizers of exhibiting a hypocrisy that stank unto the heavens, because of our not altogether charitable treatment of Blair Internet when he was alive. Those of us who had made the calls to Blair and his shrinks, who went out and met his brother and his mother and tried to provide them some comfort, had a different attitude toward those who couldn't bring themselves to attend the painful event in person but didn't hesitate to heckle others Internet. People who had to live with each other, because they were all veteran addicts of the same social space, found themselves disliking one another (p. 37)." There has always been a lot of conflict in the WELL, breaking out into regular flamefest of interpersonal attacks from time to time. Factionalism, Gossip Envy. Jealousy Feuds. Brawls. Hard feelings that carry over from one discussion to another (p. 53)." Thought, feelings, and behaviors are the raw materials of counseling Rheingold's experiences provide poignant insights into the thoughts, feelings and behaviors Internet and in the real life of a multinationa~ Internet, social community From social psychology, the construct of disembodied engagement and personal interaction over the Internet has been named "presence". Lombard and Ditton ( 1997) identify presence as the sense that mediated experience ( computer, simulation rides, home theater, video conferencing) is natural, immediate, direct, real and unmediated. This qualitative factor of mediated communication is crucial to community building and counseling. "An enhanced sense of presence is central to the use, and therefore the usefulness and profitability, of the new technologies ... These technologies either are now changing or are expected soon to change many of the ways we work, play and live (p. 2) Social presence theory was studied early in the advent of mass, affordable access to electronic media and continue to be important in social psychology and mass communication research.

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25 Cyber feminist Plant (1996) warned that the Internet disembodies, degenderizes and promotes yet another form of oppression Stanley (2001) and others (McLuhan & Friore 1967, Billig 1996, Shotter, 1993, Turkle, 1995) countered that language embodies the authentic self and depoliticalizes the communication. Stanley disputed the concept of virtual space saying, "a social space (is) constructed through which embodiment could be revealed This reality is "real space," the space that is on the other side of the screen ... real space constitutes the embodied practice of social talk (p 77) He suggested interpersonal life is a dynamic performance of language constructed in speaking and writing, not in thinking or holding unexpressed opinions and attitudes "Rather than language being a reflection or mirror of social life, language itself constructs social life when it is practiced. Discourses produce different versions of this social life, different realities (p. 79)." Stanley works with international students for whom life with family and friends of necessity is text based He analyzed the text-based interviews with distant students/participants and identified recurring themes. Quotation marks are used to signal 'stake' and 'accountability Subjectivity and reality, marked by the use of"humm" and "erm", Stanley noted is "an archetype of phonetic space (that) has been appropriated for use in cyberspace (p 86) He found that the bodily presence of the person using the Internet is present in the use of emoticons ( emotion icons) and by typing speed, pauses, and deletions Language itself embodies in metaphorical phrases. Boechler (2001) makes much the same argument from a cognitive process and concept point of view Much of the debate over presence and embodiment (Harris-Bowlsbey 2000, King & Moreggi 1998, Laszlo, Esterman, & Zabko 1999, Miller 1995, Plant 1996, Powell 1998, Reid 1994, Suler 1999 Walther 1996) has or needs to examine how presence,

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26 emotion and embodiment are incorporated in text-based communications Letters missives and discourses were the majo r form of communication from the invention of writing at least as early as 5 000 B.C.E. until the invention of the telephone telegraph, and radio in the last 19 th century (Bell 1867, Bell 1895 and Marconi 1900) The most common and wide spread convention for expressing emotion on the Internet is t he smiley or alternately the emoticon Early on, the need to encode and covey feelings was recognized in the computer chat space Carnegie Mellon Principal Research Scientist Scott Fahlman, (1995) admits Yes I am the one who first suggested the use of the : ) and : -( glyphs in E-mail and bboard posts sometime around 1981 People were making sarcastic comments in posts, others were taking them more seriously than they were intended (no body language on the net) and silly arguments were breaking out. So I suggested on one of the CMU bboards that people explicitly label comments not meant to be serious with a : -) glyph Very quickly, this idea spread all around the world and others started creating clever variations on the theme The awful term "emoticons" is much more recent. These glyphs (see Z Boray 1997) are an important part of routine Internet socializing but are inadequate for expressing the range of non-verbal cues necessary in counseling Other rules of appropriate behavior ( netiquette) on the Internet also evolved to smooth social interactions (Rinadli 1998) and should be observed by the cyber counselor but like glyphs netiquette is not sufficient for the needs of the counseling relationship The introduction and development of glyphs and netiquette demonstrate that the need and convention was recognized early in the development of text-based communications

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27 Cyber counseling specific conventions have been developed and need to be researched developed enhanced and expanded Murphy and Mitchell (1998) developed a three-component convention to provide a text-based alternative to the non-verbal cues in traditional counseling Technique 1 is called emotional bracketing" In the text of an email or other text-based communication, the writer puts the emotional tone of his or her thought in parentheses (p 24). For example, a therapist may be concerned because the client mentioned his car was stolen then skipped without elaboration to another topic The therapist might write Let me interrupt here and return to your mention of your car being stolen ( concern, puzzled) What have you had to do as a result .. police public transportation, .. ? I know you frequently have to take your aunt to doctors appointment (proud of your commitment)? How are you coping (knowing you have ) ? The second tool or technique Mitchell and Murphy developed is called alternatively textual visualization or descriptive immediacy" They provided the following example : If you were standing beside me as I write this Tanya, you would notice me stopping often, falling back against the back of my chair saying "that s incredible" to myself. Your recent successes against guilt are so wonderful that even now I find myself (right now!) Stopping in the middle of the sentence my hands towards the computer screen, my mouth wide open as if to say this is amazing How did she defeat guilt?" (p 24) Third Mitchell and Murphy encouraged the conscious deliberate use of literary tools simile allegory metaphor poetry, story telling and mythology commonly used in face-to-face therapy These techniques have expanded the repertoire available to therapists well beyond the effective but static emoticon or smiley for expressing

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28 emotional context for making content explicit and for making the here-and-now process comments so vital to counseling in text talk. Another equally interesting concept is "hyper-personalization ". Walther (1996) introduced the concept of a reinforcing feedback loop which he called an intensification loop He suggested that a person can project his or her idealized self into the communication and be reinforced for that idealized self, increasing the realizat i on of that ideal in their daily off computer life via ego strengthening. He also suggests that when communicators do not have to pay attention to social cues they pay more attention to the text and its meaning. He did not however, discuss whether this enhances or distracts from therapy Patterson (2000) and Riemer-Reiss (2000) each reviewed Internet rehabilitation service delivery and concluded that the Internet offers accessibility immediacy advocacy and competency for rehabilitation counselors and their consumers and also challenges and ethical considerations Patterson mentioned the availability of vocational information Department of Labor Statistics job banks placement resources medical information free or inexpensive assessment tool ( e g Keirsey Type Indicator Career Interest Game Career Key Birkman Method Career Style Summary and the Self Directed Search) support groups and continuing education. Patterson advised "judicious use to complement the work of human interaction. Mutual trust or trustworthiness Trustworthiness consisting of dependability reliability and honesty is essential to a good counseling relationship (Ainesworth 1995) These mirror the qualities Roger s (1957) included in what he considered necessary and sufficient conditions for person centered therapy to be effective. Trustworthiness on the Internet has been researched by

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29 Cheskin Research and Studio Archetype/Sapient (1999 because of it is vital component in ecommerce. Web site and email security were discussed in length below because cyberspace is mysterious to many users and because privacy, confidentiality and credibility are essential factors for instilling a sense of trust. Intimacy Intimacy, in a clinical sense, has to do with the amount of self-disclosure exists in a relationship (Robson & Robson 1998). As a relationship develops and matures, the amount of self-disclosure increases and expands. For counseling, self-disclosure is essential. Self-disclosure must be monitored. Too much self disclosure, prior to sufficient development of presence and trust, can rupture a budding relationship just as too little disclosure later in a relationship can regulate it to distant, formal, casual and atrophying because it lacks depth and richness. Social presence, mutual trust and adequate and appropriate intimacy or self disclosure exist on the Internet and are richly communicated through email, chat rooms, bulletin boards, and multiuser domains. This research (Sproull 1997, Robson & Robson 1998, Barak 1999, Suler 1999, Mantovani 2001, Stanley 2001) is fundamental because without these factors, counseling could not realistically expect to develop a human relationship and personal bond needed for a therapeutic alliance to move the therapy to a satisfactory outcome. Internet Counseling Issues Website Security Counseling room security is a significant concern especially in university teaching labs and public clinics where sound readily passes through the walls. The problem of "eavesdropping" escalates on the Internet. Electronic transmissions are most vulnerable

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30 to security breaches at their origin and at their destination. In transit, the message consists of binary code that has been broken into several "packets" each of which travels the Internet independent of the other. At the destination, they are reassembled and checked for completeness Security should be applied at each end point where the message is complete and readable but the counselor can only control his or her end of the communication It seems obvious that therapy should not be conducted from the client's employer's computer or from a public computer (library, computer cafe, etc ). Ironically these sites may be the client's only Internet access Law and legal intervention cannot secure wireless connections to the Internet. Hardwired cable modems or DSL cables are also at risk because they establish a permanent address for the computer access rather than a new one with each dial up making the connect susceptible to deliberate attack. Dial up connections are vulnerable to disruption of service The client and therapist each have to be responsible for common sense and security on their respected ends of the transmission. Grohol (2001) who credits himself with creating the term "e-therapy" claims that e-therapy is more confidential and secure than traditional psychotherapy citing thin walled clinics, and patient charts available to clerical personnel as evidence oflack of security in a traditional office or clinic Grohol does have a point to the extent that unless a therapist sound proofs his or her therapy room, encrypts all telephone calls to patients/clients, and checks the office regularly for surveillance devices, does his or her own transcription, copying and filing and so forth, most Internet psychotherapy is as secure as its face-to-face counterpart Workers Compensation required that all case notes relevant to the injury be copied and submitted with the request for payment. How secure

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31 is that? Physical security is the most crucial place to insure office or Internet privacy and confidentiality. (Smith 1997) In recent spy scandals, the main issues involved missing disks, missing laptop computers, and missing hard drives, not Internet or Intranet security Encryption (Smith, 1997) offers the second mode of protecting Internet privacy but has no application if one uses a cell phone or wireless Internet connection ( encryption is legally defined as a munitions in the USA and 40 other countries). Ironically it is the geographically remote who rely on wireless communication. The average user can connect to the Internet in one of three ways. Dial-up connections use regular telephone lines. In remote areas, some telephone lines still use analog (rotary pulse) system and cannot dial up an Internet Service Provider (ISP). Television cables offer another way to connect to the Internet but cable television is likewise not economically feasible for the companies in remote areas and therefore not available to one of the most under served populations Dish satellite is available in remote areas but because it is wireless, it cannot be legally encrypted. Most high-speed Internet connections rely on microwave towers and as a result are wireless even when offered by the local telephone carriers Cable high-speed Internet connections are probably the only DSL connections that use physical wire. Internet security is a matter of therapist knowledge and proper application of both hard ware and software solutions (Smith, 1997). T-4 lines are the most secure, most expensive, and least available to the average therapist. Furthermore, even if the therapist has a secure high-speed connection, the actual communication between a therapist and client can only proceed at the rate of the slower system

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32 The issues for email, chat, and bulletin board security include authentication, non repudiation, public key distribution, and mailing list handling (Smith 1997 p 287-296) Authentication asks "who wrote the message" did the therapist write the message the client receives, did the client write the message the therapist received Non-repudiation is important in legal matters commonly business contracts but, for the therapist and client in potential lawsuits -divorce custody criminal, and malpractice Public keys are passwords and other encryption devices use to allow discretionary access to information Mailing list, ( e.g ., listserv, USELIST) are difficult to encrypt because the decryption must be specific for each receiver. Cryptography and secret codes has a long history in government, intelligence and military use but equally if not more importantly in business and commerce Modem cryptography has been spurred by the business and commercial needs of the Internet and by major advances in modem mathematics that provides the means to develop nearly indecipherable code algorithms The therapeutic community is rightly concerned about privacy and confidentiality However "hacking" or breaking into a properly secured computer system, is actually very difficult rare and targets valuable and marketable sites With this caveat the therapist is wise to encrypt his or her site for the protection of the therapist/client communication and use a third party secure payment company which specializes in the coding/decoding in monetary transactions This protects both the therapist and the client from external credit card fraud exploitation, and subterfuge It is the most complex, expensive and restrictive form of encoding Companies exist to handle financial transactions because the ordinary transactions of many businesses are not worth the time and trouble required to intercept or forge them It is a much better

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33 business strategy to hire out secure credit card processing than incurring the expense and risk of doing it in-house Mitchell and Murphy (1998) recommend that all e-mail be encrypted but agree that it may be too anxiety producing to ask of a client seeking professional help to acquire and learn to use an encryption program (p 52) E-mail can be encrypted with free or inexpensive software but it only works if it is installed and used properly PGP (Pretty Good Privacy) encrypts both e-mail and files for a one-time cost The software "plugs in" to common email programs such as Endora or MS Outlook, to encrypt files disks and existing email on a hard disk ZixMail is a secure email application, which downloads free but requires $1 per month payment. Zip-Lip and HushMail are both free secure web messaging services. Messages remain on the server so they cannot be intercepted. Nothing is stored on the clients' computer or the therapists' computer (HON, 1995) The major concern about the use of encryption software is not the quality and usefulness of the software, but the misuse or inappropriate use of the software (Smith, 1997) The electronic security issues, technological failures and access have as long a history of research and development as do research on therapy relationships and outcome efficacy (Wright & Greengrass 1987) Electronic security is directly related to ethical issues of privacy and confidentiality While news media seem to frequently report breaches of electronic security a close examination of recent espionage incidences reveal that most involve an insider (Lee Ames, Hansen) who has direct, physical access to the hard drive server stolen laptop software, encryption/decryption devices or paper files Virtual Private Network (VPN) is the concept of using private computers ( desktop

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34 laptop, mainframe or server), firewalls, public servers, the Internet and the client's personal computer (Barlow 2001 Fratto 2000). Certification authority issue digital signatures after performing background checks to assure that the company certified is what it claims to be The personal digital signature certificate verifies that the user is who he or she claims to be. Loss or misuse of a digital signature certificate has serious consequences, comparable to loss or misuse of a passport A digital signature is also analogous to a business or occupational license and bonding. Legal Considerations State licensure and states rights are the key legal issues in Internet psychotherapy. Federal and state laws regulate Telemedicine (Congress 1997, HCFA 1996 HCFA 1999). Interestingly, both California and Minnesota have passed laws allowing reimbursement for telehealth services (Jones 1996a, Jones 1996b). California (Maheu 2001) has also passed an Internet psychotherapy law restricting practice to in-state clients Case Managers, rehabilitation counselors, and nationally certified counselors in states without licensure may be relatively safe practicing under their national certification. There is ultimately no way to know if the person with whom the therapist is communicating is physically located in a state or nation where the therapist has a license or certification As a result, much of the experimental research on Internet psychotherapy is being conducted in Israel (Barak 1999, Barak & Wander-Schwartz 1999), Australia (Reid 1994, Smith 1997), and Canada (Murphy & Mitchell 1998, Mitchell & Murphy 1998). Dunaway (2000) discusses both jurisdiction and malpractice insurance issues "The potential for out-jurisdiction counseling is another hurdle faced bye-therapy State licenses restrict providers to practice within a state, but patients on the Internet can reside

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35 anywhere. This is an unsettled area, so it is smart to take a conservative approach until further guidelines are developed." She advised, "generally speaking, unless there is a specific disclaimer in the insurance policy, the carrier would have difficulty denying coverage for malpractice claims for work within the scope of mental health treatment by a licensed psychiatrist Therefore, a licensed professional may be covered for liability while practicing on the Internet but geographic scope of practice area is a concern Grohol however points out sadly, that licensing boards are infamously inactive in pursuing complaints and taking action against licensed professions His advice is to practice within professional ethical guidelines and within one's expertise and let case law evolve (Grohol 1999a). Modalities Telehealthff elemedicine The American government and military interest in the Internet included all aspects of defense including the health and care of personnel in remote areas. Telehealth/ Telemedicine is the branch of Internet use and research that provides electronic healthcare to military and civilian populations who lack readily available geographic access to medical care E-mail Therapy via e-mail is currently the most widely used form of Internet mental health service outside Telehealthffelemedicine, and the most accessible to clients and therapists E-mail was an after thought of Internet developers who found it convenient to communicate with one another involved in a complex project design It requires minimal bandwidth and can be accessed with an "appliance" for those who cannot afford a computer E-mail service can be obtained from several free sources.

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36 Murphy and Mitchell (1998) developed techniques described above and wrote about their qualitative observations from conducting therap-e-mail on their web site http://www.therapylnternet.ca. They required potential clients to complete and return an on line form called the Virtually Solve It worksheet, which can be completed off line They believed that the permanent record of email makes consultation and supervision easier. A response can be reviewed by the supervisor, consultant or peer prior to being sent to the client (p 26). The permanent potential of email encourages the therapist to be thoughtful and behave in an ethical manner (p. 27) Clients found that filling out the VSI and writing out their interactions with the therapist externalized their problems making them easier to confront and resolve (p 27). Repeated efforts to obtain this form were unsuccessful, so it appears no longer to be a viable web service, however Grohol' s site is active and has pre-therapy form at http://psychcentral.com. Mitchell and Murphy recommended that further research should be conducted to study the impact and effectiveness of their techniques ( emotion bracketing and textual visualization (descriptive immediacy); application of narrative and solution focused therapy in face-to-face and electronic therapy; impact of writing itself in the therapeutic process; and pre-treatment effect of writing to the therapist ( e g., using the VSI)( p 30) Chat/Conferencing Suler (1997) describes text talk as austere because it lacks voice, facial expression, body language and visual/spatial environment. While some may find this disorienting, he suggested that for many, text-talk is a more direct, intimate mind-to-mind communications approximating an internal dialogue. In his study, Suler analyzed "many megabytes" of saved logs exploring the concerns that the absence of visual and auditory cues confuse users, and lead to painful misunderstanding He identified

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37 phenomena of text-based conversation There is often a lag in live messages due to Internet connection speed He called these out-of-syn occurrences, temporal hiccups. This can seem similar to talking over another person in face-to-face conversation The Internet therapist will need to determine whether he or she is viewing a temporal hiccup or an interpersonal issue. Most chat modes providers, including AOL and WEBCT (used in this study), allow for only a line at a time text entry (plus cut and paste for large pieces of text). Correspondents don't actually see what the other is typing until it is published using the enter key ICQ in live mode however allows for a more natural ongoing conversation limited only by the speed/skill of the typist. Writing is live rather than written then sent. There is software that allows one speaker to complete a lengthy thought before the next message posts and was used extensively in Taylor's AOL Dream Group Therapy Suler (1997) developed a convention of "listening". When one person was clearly caught mid-sentence or mid-thought by the limitations of the program, others "need to sit back in a 'listener' mode. Some users will even type "listening to Joe" to indicate this posture to others (p 5)". He describes "staccato speak" as a joking around or playful exchange, a group "free for all ( p 6)." His illustrations are reminiscent of the "Fireside 5" or "Monty Python" comedy routines ( p. 6). Suler includes acronyms (e g., brb for be right back) under this category but this researcher tends to see acronyms as more similar to emoticons, emotion bracketing and other text talk enhancement. The occurrence of "staccato speak" (minus acronyms) in psychotherapy could signal anxiety or avoidance of painful emotions.

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38 Barak et al (1999) conducted one of the only empirical studies reported He and his team chose synchronic chat groups for their research because e-mail, the most common form of Internet therapy, "lacks a key feature of human interpersonal communication characterized by spontaneity, authenticity immediacy and directness. This feature is directly related to the commonly accepted and generally appreciated therapeutic factor of here and now Numerous schools of psychotherapy argued that this immediacy factor may be responsible to a great degree for dramatic therapeutic developments. In addition, defense mechanisms or cognitive distortions ( depending on the school of therapy) are less. likely to take place in a "here and now'' therapeutic situation (p 1 )" In this study of brief Internet Chat room group therapy, Barak recruited 15 students from several Israeli universities and community colleges Six participants (three men, three women) were assigned to the Internet condition and nine students (three men and six women) were assigned to a traditional face-to-face group therapy Both groups were led by experienced, female therapists and were brie( dynamically oriented One therapist conducted the Internet group while the other conducted the face-to-face group therapy. The Internet condition was conducted in a JavaScript, password protected chat room for seven, ninety-minute sessions The face-to-face group met on the campus of the University of Haifa. The dependent measures were Measure of Therapy Impact : Self Esteem, Social Relationship, and Well-being Each scale was a 25 item Likert-like scale but Barak does not cite the source of these measures Moose (1981) developed the group process measure, a Likert-Iike evaluation questionnaire designed to elicit opinions about the Internet group therapy experience Because of the small number of participants in

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39 this study, the data were evaluated qualitatively by analyzing chat room transcripts in addition to reviewing the results of the dependent measures. Results indicated that participants exhibited positive support, personal disclosures, interpersonal sensitively and group cohesiveness. No comparison with the face-to-face group was reported. Recommendations for further research include a study of preparation for therapist for Internet therapy, and rules by which such groups should operate (Barak & Wander-Schwartz, 1999). Multi-modal Colon (1994), a prominent social worker, conducted one of the first studies of Internet psychotherapy She conducted a three-month study with eight participants using email, chat and bulletin board. Participants were recruited and screening Internet from ECHO subscribers Participants were screened, refrained from in person contact with one another or Colon, posted/participated actively at least three times a week and participated for three months. Colon's training was psychodynamic and so were her Internet groups. Her primary concern about the experiment Internet groups was the absence of non-verbal cues. (p. 9) She concluded "In Internet therapy and perhaps in the psychoanalytic session, language is action Nothing "happens" Internet, or for all intents and purposes, in therapy There is no way to quantify what happens in an Internet group And yet lives can change Phillips (1996) qualitatively compared four groups within which she participated, an Internet service Adult Children Of Alcoholics (ACOA) chat group, an Internet service ACOA email list, an Internet ACOA email list and an ACOA chat group she created on the Internet service None of these groups appear to be formal groups with regular attendance, ground rules and on going interaction as defined by Yalom (1995) whom

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40 Phillips cites extensively She reported that each group was roughly organized along the 12-step philosophy Her discussion indicated that she was a participant in the first three groups rather than a researcher or group leader She briefly touches on private conversations (IM) cross talk, advice giving and anonymity as assets of Internet groups but there is little research in group therapy to support these as constructive which she acknowledged but saw as a positive difference between in person and on line groups Suter (2000) complied a list often issues to consider in developing understanding in Internet groups and communities These are general considerations about the uniqueness of the Internet rather than group process constructs. Unidirectional Information Only Many Internet using therapists are cautiously waiting for legal issues to be resolved and are providing only information, advice, or recommendations, but not psychotherapy Grnhol' s forced and constrained definition of e-therapy demonstrates this caution (Grohol 1999b Grohol 2001), while he is, paradoxically one of the most outspoken researchers defending the legality of Internet work (Grohol 1999a) Unidirectional information is generally health related articles, electronic journals and patient information sheets (e.g ., WebMD com, MayoHealth.org). Guidelines for Ethical Practice of Internet Counseling The need for ethical guidelines to direct the development of Internet psychotherapy services was recognized by all major mental health organizations almost as soon as the Internet became commercial The Health on the Net Foundation published HON Code of Conduct for Medical and Health Websites (HON 1995). Two years later, in 1997 the National Board of Certified Counselors published Standards for Ethical Internet Counseling; and the American Psychological Association published Services by

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41 Telephone, Teleconferencing, and Internet : A statement by the ethics committee of the American Psychological Association). In 1998 the American Medical Informatics Association published Guidelines for the Clinical Use of Electronic Mail with Patients The American Counseling Association published Ethical Standards for Internet Counseling in 1999 The International Society for Mental Health Internet and the Internet Health Coalition each published their standards in 2000 In 2001 the American Psychiatric Association published American Psychiatric Association principles for medical ethics with annotation especially applicable to psychiatry. In a pilot study Mitchell and Murphy (1998) examined the email therapeutic relationship with one client who had engaged in over 100 transactions with the therapists In 1995, the researchers had set up a pilot counseling site on the local computer bulletin board service. They limited access to counseling services to two thousand members The services offered were the Virtually Solve It worksheet (VSI) an Internet form design to help the potential client explore and externalize the problem. They introduced therap e-mail and Ask PATtYQ which stood for Professional Answer To Your Question In 1998 they interviewed the one client chosen for qualitative response to issues being debated by the National Board of Certified Counselors committee on WebCounseling ethics security issues physical absence, emergency situations technological failure therapeutic relationship/efficacy and access Credential Validating Referral Sites Reliability credibility and freedom have been the core values of Internet developers almost since its inception and certainly, since it became available to the public Switzerland is home to two of the primary Internet regulatory bodies the WWW Consortium and Health On the Net Foundation http://www hon.ch/ @HON. The W3

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42 Consortium sets voluntary but fairly universal technical standards used in HTML JavaScript and other development and implementation design tools @HON which organized in 1997 sets standards for health and health related web activity @HON has a strict enforced code of conduct in seventeen languages requiring trained and qualified professionals support not replacement of traditional care confidentiality appropriate credit to source materials justifiability of products or services transparent authorship transparent sponsorship and honesty in advertising and editorial policy @HON enforces compliance in several innovative ways The @HON logo which is displayed on certified web sites is active or live ". When a web site visitor mouses-over the @HON logo it will link to the @HONcode web site Non-certified web site designers can copy the logo to their web site but cannot copy the active link Web users are aggressively encouraged to report any non-active links for @HON team action The @HON team uses the active link to perform random web site checks To earn the right to use the @HON active link logo the web site designer must complete a detailed application and submit to a @HON team examination of the Web site The applicant must make changes required to come into compliance with HONcode (HON 1995) @HON is recommended by such prestigious American medical organizations as the Mayo Clinic "When you vis i t a health Web site look for a logo from the Health on the Net (HON) Foundations. Sites that display this logo agree to abide by the HON Code of conduct. Some sites may choose instead to publish a statement explicitly affirming that they are in compliance with the HON Code of Conduct (Edwards 2000) ." The International Society for Mental Health Internet http://ismho.org/ and WebPsych Partnership sponsored by ISMHO http://www.ismho org/webpsych/ are the

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43 major American based mental health Internet research, development and self regulating organization Membership and use of the ISMHO logo on a web site is open to any one, professional, consumer or other, who is interested in the development of mental health resources on the Internet, for a modest annual membership fee. There is no site evaluation or monitoring such as @HON uses. The goals of these organizations however, are not necessarily congruent with those of the professional organizations For example, the goal of the WebPsych Partnership is "to ensure a high quality of Members' sites and reduce unnecessary competition and harmful in-fighting." In fairness it does seem to be focused on promotion of web sites and accuracy of web sites rather than interaction with clients or other persons seeking mental health information Ainesworth s web site, http://www metanoia org, was organized in 1995 and remains one of the primary resources for information about mental health resources counselor referral and information. She is a consumer report organization She adamantly does not hire therapist or market services Her listings are free, but the therapist must meet criteria that includes having a web site which she evaluated with @HON standards communicating personally with individuals, personalizing help to these individuals and communicating with individuals through the Internet. She will not list any "sites where services are not offered by a credentialed professional psychotherapist There is a profusion of sites and listings that do not require professional criteria for inclusion, but do have some criteria Mental Health Resource with Leonard Holmes Ph D purports to be "your guide to over 700 sites"; however, these sites include related professions such as law and unrelated topics such as aliens. The criteria to list with this

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44 site indicated that a web site "should not be used to advocate or promote the following : any illegal activity activities that support or espouse non consensual and/or extreme violence or sexual aggressiveness toward another individual or group for any reason, activities that support or espouse hatred towards another individual or groups based on any criteria and activities and input from individual that violate our inclusive standards http : //mentalhealth about.com While these are laudable criteria, they fall short of mental health professional practice criteria Clinician's Yellow Pages http : //mentalhelp net/mhn/yellowpages/ ; Who's Who in Mental Health on the Web http : //idealist com/wwmhw/; Find-a-Therapist; and 1-800Therapist ; list web site for an annual fee without evaluation or monitoring, similar to a listing in the Yellow Pages of a telephone directory. Basically a psychotherapist practicing on the Internet must establish all the same security, authenticity and grievance procedures as the psychotherapist seeing clients in a physical office A physical office has a pleasant, soothing decor, locks on the doors security system, secure location and procedures for charts, requests for notes and so forth. In physical office a therapist must display, at minimum, the occupational license and the professional license to demonstrate authenticity and grievance resources. The virtual office needs an effective web site that is uncluttered, appealing, and easy to navigate There must be firewall(s) protecting the therapist's computer system, SSL across the network and easy instructions for client firewalls (locks on the doors). Authority to practice is demonstrated by posting live logos (i.e licenses) for security (e.g ., Verisign) and credentials ( e g @HON). Live logos are linked to the company and the client can instantly verify the therapist's legitimacy to the extent of each authoritative body's

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45 responsibilities No one denies that these technologies are cumbersome and may well cause therapists to think twice about practicing on the Internet or incline some therapists to practice without adequate safety precautions. Advantages of Internet Counseling The perceived advantages of Internet Counseling are it's immediacy, availability, anonymity, and economics (Brown & Walz 2000, Fink 1999, Grohol 1999b, Grohol 2001, King & Moreggi 1998, Patterson 2000, Stubbs 2000) Internet access is immediate, any day of the week, any time of day, any where in the world. One does not have to wait for business hours or for an appointment. The Internet users in search of information, companionship, and advice to get through a sleepless night, pain, or spasms can readily find help in a chat room, bulletin board or informative web site The Internet is available in many remote geographic areas where users do not have access to therapists. It is available to situationally remote users include home bound care-givers, the elderly, persons with disabilities, and those who would be at employment or social risk from seeking counseling The Internet can be anonymous. Personal information (age, gender, ethnicity, physical condition) can be disguised Web counseling is considerably less expensive than traditional face-to-face counseling The overhead of maintaining a web counseling site is much less than that of renting office space, maintaining a staff, occupational license, furniture and equipment, the myriad of taxes, and other "cost of doing business" in the traditional setting Owners of the PsychOptions site http://www psychoptions.com/raters & wes of services htm, for example, lists the following charges : One question/one problem $25; One e-consultation/first on-going session $50; On-going session $35; Telephone session $50 for 50 minutes The one question, e-consultation and on going sessions are all conducted by email. The

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46 PsychOptions site offers a sliding scale "If you have extenuating circumstances and/or are over 65 + and/or on a fixed income then you may contact PsychOptions to request an adjustment and explain the reason why." Disadvantages of Internet Counseling Internet counseling is a double-edged sword The disadvantages of Internet counseling can be the same as the advantages -immediacy reliability and validity of information, security (e g ., privacy and confidentiality) anonymity abandonment physical absence ethics legality and security (Grohol 1996 Storm & Moregg i 1998 Oravec 2000) While a potential client may be assured of a response within 48 hours while a non-crises office client may have to wait a week or two for a first appointment the quality of that first contact may be no more valuable than the first phone calls to a physical office and responses appropriately provided by trained office staff The credentials of the Internet counselor may be as valid as those of the office counselor ~ however it i s generally more difficult to verify those credentials as demonstrated above in the extensive discussion of web security. In a traditional office the client can examine see the professional license and the business license, both of which are required by law (at least in Florida) to be prominently displayed The local Better Business Bureau and Chamber of Commerce can both be contacted to check the counselor's business history and can offer recourse if problems arise As discussed above the web is developing comparable resources in @HON and Metanioa com, however they are not well known Furthermore, in a physical site the client has recourse if credit card charges personal checks and cash payments are mishandled Again the Internet offers security but many sites promise security ( e g ., affordablewellness com) when in fact they are not secure Buyer beware is never more

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47 true than in the Internet environment. PayPal.com acquired by Amazon com in July 2002 offers some of the same financial recourse as services continue to evolve in the credit card industry as e-commerce grows Unless the URL begins with https (hypertext 1ransfer Qrotocol ~ecured) the site is not secure Unless there is a small padlock icon on the status bar of Internet Explorer or Netscape the site is not secure Again, many consumers especially in a time of stress or crises precipitating contact with a counselor may not be aware of these Internet conventions To avoid the expense of a secured site, many small merchants ask that credit card numbers be emailed to the site Email can be secure but again, if it is there is evidence of that security that clients are unlike to know or consider in a time of distress Does Internet counseling provide privacy and confidentiality both in personal information and financial information? It can, but many sites do not. There is often legitimate concern in physical counseling rooms about thin walls, crowded waiting rooms and non-counseling staff access to chart notes There are however analogous problems in a cyber counseling room the client's own family or co workers may have access to the screen as the client talks with the counselor or to the records in the computer A spouse seeking a contested divorce a vindictive co-worker and other persons with agendas harmful to the client may be able to print off logs of the sessions emails or bulletin board postings Clients computer end users may or may not be aware of what is recorded in the computer program itself A client can conscientiously protect his or her email correspondences and yet never know that the chat session i s automatically being saved by the computer software The client's own associates ma y have more access to the very information that the client needs to have secure from others

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48 Another disadvantage is face validity on the Internet. A well-designed site may have powerful face validity that speaks volumes for the competence of the web designer but say nothing about the credentials and skills of the counselor. With a population accustomed to visual pleasure from screens television, movie, electronic games, and computer monitors, the design may allow totally unqualified, perhaps even harmful "counselors" to gamer large "practices". What you see, may not be what you get Anonymity, abandonment, and physical absence are closely related. The client and the therapist for that matter can disguise his or her identity on the Internet. This reality needs to be built into Internet counseling theory as the modality evolves beyond applying traditional modes to the new media. The client could also disguise his or her identity in person although it is more difficult if payment involves insurance policies or credit cards. Abandonment is a serious risk on the Internet, while it less likely to occur in a physical practice setting Traditional clients may feel abandoned when their treatment is completed, when they are referred to another mental health care provider when these issues required different skills or training, or, in a clinic setting where the counselor turn over may be high; however physical sites rarely "just disappear" the way web-sites do. Some argue that no interpersonal bond in the cyberspace can replace actual physical presences (Plant, 1996). Cognitive Behavioral Counseling Models Cybercounseling is not limited to one or a few theories or therapeutic models of counseling. Researchers have studied family (Oravec 2000), self help (Storm & Moreggi 1998), group (Barak & Wander-Schwartz 1999, Colon 1994, Suter 2000), and brief cognitive (Edelstein 1996, Palmer & Ellis 1995, Ellis 1996), therapies conducted in cyberspace This study, however, will apply the brief cognitive behavior therapy model

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49 because it is best suited to the participant population, personal growth issue-focus and alliance development. As such it provides a model appropriate for 3-session, personal growth focused study conditions. Cognitive Behavior Therapy Cognitive Behavior therapy grew out of the work of social learning theorists including Lewin, Bandura and Lazarus Prominent researchers in this important area of theory and therapy include Ellis, Miechenbaum, Beck, Burns, Marks, and Rush. Miechenbaum (p 179-198) describes the process of therapy as involving three mental constructs he calls cognitive events, cognitive processes, and cognitive structures. His theory links these cognitive constructs to emotion, behavior and logical and natural consequences of those behaviors. Cognitive events are conscious, identifiable and readily retrieved thoughts, images and feelings. They include appraisals, expectations, attributions, self statements, automatic thought and internal dialogue The person experiences them as spontaneous, and rarely questions them. These events occur when an individual is trouble shooting a problem, uncertain about an action or choice, and when a routine behavior is blocked requiring an alternative or creative solution. Cognitive processes are the mental processes by which we acquire information, store it in short term and long term memory, appraise information, filter it, and recall it. Meichenbaum identifies three cognitive processes that lead to emotional distress confirmatory bias, mental heuristics and metacognitions. Confirmatory bias is pre conceived notions or ideas that function as fact Mental heuristics in the habit of selecting experiences or information that confirm pre-conceived biases. Meta cognition is the ability, knowledge or skills to be aware of and control ones own cognitive processes The process and goal of cognitive behavior therapy is to educate the client in recognizing his or her cognitive

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50 events, cognitive processes and meta cognition. Cognitive templates or schemas are identified and the client is enabled to change those templates that no longer function in his or her best interest. Meichenbaum encourages the client to be his or her own "folk" scientist and assigns "experiments" to develop needed skills. He encourages therapists to use specific examples to identify faulty logic "We have found that people often make certain kinds of errors in the way they look at situations and that these errors in thinking may contribute to arriving at premature or incorrect conclusions It's natural to readily come to such conclusions without even noticing them (p. 193)." Logical errors include all or nothing thinking, seeing possibilities as certainties, dichotomous thinking, personalization and self blame for negative events, and over generalization. Because this theory and therapy relies on homework and experimentation by the client to reach his or her own conclusion, that affect change, it is adaptive to an Internet Counseling environment. Gabriel & Holden (lecture reported in Laszlo 1999) developed an Internet protocol for cognitive behavioral therapy, that looked at theme patterns in text based sessions They sough patterns of over generalization as indicated by the use of polar adjective, excessive self attribution of responsibility, minimizing or maximizing significant issues, and focusing on negatives (p. 296-297). There does not appear to be further information on their theory or research but it is intuitively practical. Ellis developed Rational Emotive Therapy (REBT) in 1955 and changed the name of this theory and method to Rational Emotive Behavior Therapy in 1993 to include the Behavioral component of change, which had always been present in his theory (Ellis 1998). He posited emotional and behavioral problems have their source in faulty

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51 thinking or irrational beliefs His ABC model has grown alphabetically o v er time but still focuses on an Activating event some event at work home or interpersonally that triggers the emotional crises or Consequences. The client experiences the Consequences with or without being aware to the triggering event and generally without being aware to the irrational, rigid Belief that connects a triggering event to the emotional or behavioral consequence. In REBT the irrational Belief is Disputed using cognitive skills introduced by the therapist but practiced in homework by the client. The outcome is Effective and Efficient responses to would be Activating events Ellis identified eleven irrational beliefs that cause the gamut of emotional problems Some of the websites established by founding CBT therapists are located at : Aaron Beck, M D http : //www beckinstitute org : David Burns Ph.D http://feelinggood com ; Albert Ellis, M.D Http : //www.rebt.org ; Isaac Marks M D., http : //www thisiswiltshire co uk/ ; Donald Meichenbaum Ph D http://www arts uwaterloo ca ; and A. John Rush, M.D http : //www3 utsouthwestem edu/psychiatry/facbios/rush html Brief Cognitive Behavior Therapy Ellis (1996) Beck (1979) Burns and Meichenbaum (2000) have each researched and developed brief cognitive behavior therapy protocol some of which are as brief as one session maximum benefit. In a World Counseling Network forum Ellis (1998) describes REBT as designed originally because psychoanalysis and most other forms of therapy were very long winded So I tried to devise a system that would understand the core beliefs, the core irrational beliefs of the clients very quickly and help them to get to work to dispute them and debate them in a short period of time So in a sense REBT was on to the few therapies designed to be brief (p 2) In reply to a question about efficacy

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52 of short term therapy, Ellis mentioned that "at least I 000 empirical studies .. tend to show that short term therapy at least when it is done with CT or REBT definitely is as effective or more effective than other kinds of therapy and more effective than the therapy that is given to control groups (p. 4)." He further cautioned White, de Shazer, Watzlawick and other brief therapy authors that they "had better not use the generic term 'brief therapy' to imply that they are the only form of brief therapy Ellis (Palmer & Ellis 1995) was trained in psychoanalytical therapy but realized that it takes "a fairly long time to get people to free-associate, analyze their dream and go over and over their childhood and later historical material." He describes his early work as psychoanalytically oriented as opposed to classic psychoanalysis "I found out, to my surprise ... that it was better, got better result than classical analysis . you quite quickly get their basic history (p. 68-69)." He continued "REBT is intrinsically more efficient and briefer. Often during the very first session I can show people the ABCs of distress ... So REBT is sometimes successfully done in a few sessions (p 69) In his book on brief therapy, Ellis (1996) affirmed that REBT can be accomplished with self help materials including books and cassettes that teach the REBT principles Edelstein (1996) advocated three minute REBT sessions applied twice a day focused on Ellis' construct of"musty thinking". He demonstrated that one session can be sufficient to teach the principles of Rational Emotive Behavioral Therapy and involve the client in three-minute techniques. In the forward to Edelstein's book, Ellis, founder of REBT, says "Of course it takes significantly longer than three minutes to dislodge the many dysfunctional aspects of a troubled personality But the clear and simple exercises advocated by Dr. Edelstein, exercises, which are totally consistent with my principles of

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53 Rational Emotive Behavior Therapy can be practiced in three minute segments, to be repeated several times a day. Wood (2001) describes the typical CBT length of treatment as brief. "One of the major features of CBT is the relatively short time frame required for change to begin. Some "brief interventions" were developed using the CBT approach for a one-time several minute session (suitable for application by generalist health workers such as nurses and general practitioners) She emphasized that even when these extremely brief sessions are not used CBT rarely requires more than 6-12 months, which would include scheduled follow-ups for gain maintenance and stabilization Brief therapy mandates that a therapeutic relationship develop quickly therefore numerous researchers emphasis the need to carefully select high functioning clients who have a high level of interpersonal functioning Seriously-ill clients should be referred for long-term therapy where development of the interpersonal relationship can be the focus and goal of therapy (Safran & Muran 1998) These authors recommended that early priorities in brief therapy should be to develop the therapeutic bond with warmth, respect and genuine interest, reminiscent of Rogers They offered that the therapeutic rationale, the goals and tasks needed to accomplish that goal, should be laid out in the first session They summarize their recommendations metaphorically as "part Marcus Welby and part Sherlock Holmes ." Using Brief Therapy with Undergraduates It seems reasonable to assume that most college students are high functioning by virtue of meeting admission criteria and remaining in an environment that requires self care and executive functioning. Those who are not high functioning will quickly come to the attention of the resident advisors concerned friends and faculty or the crisis center

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54 and be referred for appropriate care or encouraged to return home for care. This is not to suggest that college students do not have serious mental health issues and concerns but rather that they are most likely to have the personal talents and resources to maintain functioning through personal crises and while seeking counseling services available. Wilson (I 978) addressing common developmental problems of career direction, sexuality, belief clarification and separation from parents, went so far as to suggest classroom and resident hall intervention would provide cognitive interventions by providing problem solving development. Archer and Cooper (1998), Pinkerton and Rockwell (1994) and Steenbarger (1992) have applied the tenets of brief therapy to the target population of this study Although each of these researchers found that there is resistant on the part of colleagues to endorse brief therapy, their research and the research of others found brief therapy "to be both effective and efficient in campus counseling and mental health counseling. Luckey (1996) and Christmas (2000) addressed the use of Internet communication modalities with college students Indiana University ofPennsylvania,University Health Services (Luckey 1996) used the Internet for communication and data base processing. Because this work was written early in the public access to the Internet, its application appears to be limited to communicating with and retrieving data from colleagues rather than direct student services. However, four years later, Dulce University (Christmas 2000) was using unsecured E-mail (password protection only) with the student body population and had established guidelines for interaction with students by email. These guidelines specify the exclusion of"sensitive" information that North Carolina state law requires a health care provider to present to a client in person (e.g., positive mv lab

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55 results, pap smear results, worker's compensation information, and some prescriptions) It does not appear that Duke University student health services were providing counseling services via the Internet; however the guidelines do not seem to exclude such use as long as topics precluded by state law from remote access were not discussed It is significant that Duke University was not using an encrypted site Undergraduate Personal Growth Concerns University administrators, entrusted with the education, safety and well-being of hundreds of thousands of young adults, many of whom are away from home for the first time, have needed to know the kinds of stressors, issues, problems and concerns typically manifested on a college campus Murphy and Archer (1996) identified thirteen academic stressors and fifteen personal stressors in a survey of 639 students attending the same university as participants in this study Academic stressors confirmed by a significant number of respondents included tests and finals, grades and competition, professors and class environment studying, finances, papers and essays, speaking in class, and others. Personal stressors confirmed at a significant level were parental conflicts and expectations, finances, interpersonal conflicts, judgment and acceptance by peers personal achievement and goal setting, approaching and meeting other students, general adjustments to change, personal appearance, current job, and other The "other'' category allowed students to include stressors not mentioned in the survey. The most frequent "other'' was not getting enough sleep, followed by finding time to get everything done Other statistically significant stressors were family member illness or injury, personal health, and pledging These are the types of issues thought to be appropriate for personal growth sessions conducted during this study. The study illustrated that while the rank order of problems changed from 1985 to 1993 changed, the categories remained the

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56 same. The same is assumed to be true between 1993 and 2002; however it recognized that the wide spread access to the Internet, the university requirement of personal student ownership or ready access to computers, the use of Web based and distant learning and the events of9/11/01 may have generated new categories of concern not relevant in 1985 or 1993 although no such new categories were observed in the present study Individual Information Processing Differences Many factors have been demonstrated to influence how individual process information such as therapy input and tasks results Some of these include environmental and cultural variables such a race, gender and ethnicity, brain lateralization with emphasis on processing information verbally or with images, and personality traits including introversion and extraversion. Demographic Factors The major premise of the huge national investment in Telehealth/felemedicine is that technology provides a method to reach under served populations -women, undereducated citizens, rural citizens, Native Americans, citizens with disabilities, and citizens of color (HCFA 1996, HCFA 1999). The concern of researchers (Reid 1994 Powell 1998) is that the price of technology, and the education and experience required to uses these resources may effectively exclude the very populations it is thought to most be able to benefit. Powell (1998) found that the majority of Internet therapy users were male. Learning Style Theory Learning style, brain lateralization, and information processing research and theory have contributed a substantial body of information indicating that people encode, process and retrieve information in distinctly different manners. Two style systems are of

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57 interest to the present research, academic oriented learning styles and temperament based learning styles Academic learning style theory addresses specific skills and tasks generally incorporated into formal pedagogy Temperament based learning styles affect how the individual learns formally or i nformally by his or her inborn nature and traits Academic Learning Styles Of the researched styles verbal visual, kinesthetic, group individual oral expressive and written expressive (Babich, Burdine Albright & Randol 1976) the most consistently identifiable and validated styles have been visual and verbal (Lazarus 1964 Richardson 1969 Richardson 1977 Delaney 1978 Dyckman & Cowan 1978 Akins Hollandsworth, & O'Connell 1982 Akins Hollandsworth, & Alcorn 1983 Pavio & Harshman 1983 Macinnis & Price 1987). Richardson (1969) cites a late 19 th century researcher Lay who illustrated his concept of the misunderstanding among people as being a result oflearned or innate preference for verbal processing or visual processing with the historical animosity between Greek philosophers Socrates who "heard the voice of his daemon and Protagoras who thinking and debating relied upon visual/kinesthetic processes Richardson quotes Lay as saying if one is auditory-linguistic he should never enter into an argument with a motor-linguistic person, as on all topics except the most concrete facts either will inevitable fail completely to understand the other (p 83) ." The preference many mathematics students have for either word problems or equations is a relatively common example of the encoding processing and retrieval impact of verbal processing or visual/symbolic processing respectively Lazarus (1964) deemed visual processing to be a crucial factor in systemic desensitization therapy Now nearly 40 years later the question must be asked if the ability to visualize a virtual counseling

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58 environment is an individual difference in the ability to developed a therapeutic working alliance and produce a satisfactory therapeutic outcome. As potential clients are evaluated for cyber counseling, should their preference for verbal processing or visual processing be considered? Visual Learners Macinnis and Price (1987) summarized the role of visualizing in marketing as "a processing mode in which multisensory information is represented in a gestalt form in working memory ." The visualizers were found to use daydreams and fantasy in addition to graphically and pictorial representations in problem solving. Babich (1976) operationalizes the visualizing construct as the preference or ability to learn from seeing words or numbers and remembering spoken information by writing it down Richardson ( 1983) found that the visualizer's thinking processes consisted of pictorial or visual images The visualizer attended to the spatial layout, physical features, and sensory input of information to be encoded Verbal or Auditory Learners Babich, Burdine, Albright & Randol(1976) operationalized the verbalizing construct as a preference for hearing words or numbers spoken and noted the common practice of verbalizers to vocalize or move the lips or throat while reading written materials Richardson (1983) found that verbalizers' thinking processes consisted of spoken words or self-verbalizations, that is, linguistic encoding, labeling or naming He likened it to an experience of inner speech

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59 Temperament Leaming Styles A second widely used learning style indicator has been developed by educators using the MBTI temperaments (rather than types). The learning styles are SensingPerceiving (SP), SensingJudging (SJ), iNtuitingThinking (NT) and iNtuitingFeeling (NF). Dean (1997) noted that these four personality were recognized as early as 450 B C.E These four temperaments are found in the sixteen types associated with the Gallagher (2002) describes people with the SJ temperament as guardians of tradition or traditionalists, learning from the past. People who prefer to use the SP functions are artisans and experiencers who learn best from their own work and experience. People who draw primarily upon the NT functions learn best conceptually looking for rationale, explanation, theories and hypotheses. People who depend most strongly on the NF functions are seen as idealists and learn inductively Sensing Perceiving Dean (Dean, 1997) proposed that people using the SP function combination or temperament are similar to those C.I.T.E describes a kinetic tactile, preferring hands on and active learning situations, which offer the opportunity to construct, operate and manipulate objects Sensing Judging People using the SJ learn best when their classroom, counseling environment, or other learning situation provides clear expectations and a "right way" to do things Clear directions, specific extra-therapy assignments and an overtly structured session are valuable assets to learning for those using the SJ functions

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60 Intuitive Thinking People using the NT style learning well from long-term independent projects experimentation, inventions and complex problem solving This style is somewhat similar to the visualizer and group independent style Intuitive Feeling NF users need cooperative personal relationships and learn best in a friendly atmosphere. They do not do well in rote, non-democratic environments They prefer ideal relationships and excellent interpersonal communication skills somewhat similar to verbal or auditory learners Learning Style Conceptualization Comparison It should be noted that although there are some similarities between the C.I T.E. learning styles and the MBTI learning styles they are not redundant and each offer a different perspective on learning Designed for the classroom, the C.I T.E learning style taps actually educational activities preferences in its items and classifications while the based on the broad Jungian theory of personality and temperament is more generalized and perhaps more applicable to life long learning in an educational format and well as in life in general learning Therefore both measures were used as independent measures in this study Measuring Information Processing Richardson (1977) developed the Verbalizer-Visualizer Questionnaire to access the extent to which one's thinking processes consists of words or self verbalization versus pictorial or visual images ." It consists of 15 forced choice items adapted from Paivio s

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61 86-item Ways of Thinking Questionnaire The questionnaire was normed using junior high school students While Richardson examined information processing in social psychology education psychologists Babich, Burdine Albright and Randol (1976) developed a learning style inventory, which is widely used today. They targeted three areas of concern information processing work conditions and expressiveness preference It is the information processing visualization, verbalization that parallels the social psychology work. Items were drawn from the same source material as the Visualize r Verbalize Questionnaire has more extant reliability and validity data, is published and readily available and has been used extensively in education, adult education, career counseling and vocational rehabilitation The Center for Innovative Teaching Experience Learning Style Inventory (C.I T E.) is used by the Veterans Administration and public school districts across the country to identify learning styles and to guide instructors counselors and teachers in designing learning experiences to maximize the students = use of their preferred learning style The West Virginia Adult Basic Education program uses the CITE as its primary assessment instrument to guide recommendations for tutorials, adult learning experiences and vocational training Myers and Briggs (1962) developed an extensively studied widely used assessment tool the Myers Briggs Type Indicator (MBTI) to measure the individual s trait preferences consistent with Jung's theory There are four independent dimensions introversion/extroversion ; sensing/intuititing ; thinking/feeling and judging/perceiving Interpretation of the type involves hypotheses about the interactions of these dimensions and involves understanding of dominant functions auxiliary inferior

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62 functions and so forth The result of an MBTI is one of sixteen types that purport to describe a person s inherent functioning and are used to help people understand why others respond differently in the same situation Keirsey and others have focused on temperament grouping and developed their own variations on the MBTI ; however the MBTI was used for this study because it provided both the learning style data and personality trait data discussed below. Personality Attitudes Except for those clinicians who practice radical behavioralism, individual traits play a prominent role in the planning conduct process and outcome of psychotherapy Jung ( 1923) was once of the earliest psychiatrists to postulate personality types He identified polar attitudes that he called introversion and extraversion. In the MBTI user's manual Myers (1962 p 9) describes extraversion as a trait or attitude of people who like to focus on the outer world of people and activity They direct their energy and attention outward and receive energy from interacting with people and from talcing action She describes introversion as an attitude of people who like to focus on their own inner world of ideas and experiences They direct their energy and attention inward and receive energy from reflecting on their thoughts memories and feelings. Eysenck (1970) suggested that personality is biologically determined and is arranged in a hierarchy consisting of types traits habitual responses and specific responses Eysenck built upon Jung s theory with empirical research describing a structure of personalit y along three dimensions one of which was introversion-extroversion Brinegar (1992) researching the predictive value of the MBTI in counseling outcome found that "extraversion-introversion dimension surfaced as the only single dimension score to be significantly correlated with counseling outcome Myers as early as 1962 suggested

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63 implications for counseling based on type and counseling goal vocational and career, education and learning, organizational team building and provides guidelines for using introversion/extraversion (as well as other scales) appropriately in each setting Introversion The trait of introversion is generally associated with a preference for communicating in writing, working out ideas by reflecting on them, being private and self contained, and for taking the initiative when a situation or issue is very important to the person (Myers 1962). Extraversion The trait of extraversion is seen in people who are attuned to their surroundings, communicate verbally, problem solving by talking through issues, and learn by doing or discussing (Myers 1962). Measuring Personality Attitudes While Jung, Briggs, Myers, and McCaully all thought and taught that the dimensions are dichotomous, several researchers (Mendelson 1965, Girelli & Stake, 1993) examined the scales as continua and suggested that the forced choice format of the forces the bipolarity artifact, underestimating the true continuum of the dimensions The current protocol for scoring the MBTI has keys for calculating the degree of introversion/ extraversion for example rather than regarding them as dichotomous categories For the purpose of this study, the scales were treated as discrete traits. The dimension relevant to this study is Introversion/Extroversion. Livingood (1995) found that ''the number of introverts on these (Internet mail lists by MBTI type) is five times greater than the number of extroverts However, in the United States at large,

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64 introverts are a minority group comprising only 25-300/o of the total population (p. 8)." While intriguing, this may be skewed by the obvious fact that the mailing lists are presumably drawing from a world population rather than a US population Livingood himself writes from Australia. This perception may also reflect the observation that the people who first had access to the Internet and continue to have predominate access to the Internet are engineers and scientists who make up that 25%-30% of American introverts (Myers 1982) The use of the introversion/extroversion scale in this study is significant because the study population is United States citizens or international students choosing to study in the United States The participants were recruited from the College of Education rather than engineering or science Counseling Process and Outcome During the first half of the 20 th century, researchers primarily focused on understanding the psychological processes that affected the well being of the population. This research generated the great theories of personality and the applied therapies have helped people enjoy a better quality of life for three generations. In the second half of the century, researchers began to examine how the therapies produced the results that were anecdotally abundant. They examined what factors, conditions and environments that increased or decreased the efficacy of therapies. Financial accountability in government health care service has driven research in outcome efficacy and consumer satisfaction for the past two decades In the mental health field, this research has taken two primary directions, efficacy of the counseling process, the helping relationship, (Gaston 1991, Greenson 1965, Hartley & Strupp 1983, Alexander & Luborsky 1986, Klee, Abeles, & Muller 1990, Kobotovic & Tracey 1990, Horvath & Symonds 1991, Horvath, Gaston & Luborsky 1993, Horvath & Luborsky 1993) and efficacy of the over all experience,

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65 consumer satisfaction (Becker et al. 2000, Cialo 1982, Eisen, Leff, & Schaefer 1999, McCullough 1993, Preston 2000, Treadwiell, Soetikno, & Lenert 2000) Working Alliance For several decades, researchers have attempted to isolate the therapeutic method or technique that was most effective This research had limited results when the broad concept the interpersonal milieu of therapy, first introduced by Freud as transference was examined. Clarkson distills from the literature and her diverse theory training, five relationships between therapist and client, which strongly inform this study. Although not all these relationships may exist in any given therapeutic relationship, and may not be recognized by all theoretically orientations, each is potentially available within computer-mediated therapy as in the face-to-face work, however it was the first, the working alliance, with which this study is primary concerned. Identified therapeutic relationships include "The working alliance as the part of client-psychotherapist relationship that enables the client and therapist to work together even when the patient or client experiences strong desires to the contrary The transferentiallcountertransferential relationship as the experience of unconscious wishes and fears transferred on to or into the therapeutic partnership The reparative / developmentally-needed relationship as intentional provision by the psychotherapist of a corrective, reparative, or replenishing relationship or action where the original experience was deficient, abusive or overprotective The person to person relationship as the real relationship or core relationship as opposed to object relationship The transpersonal relationship as the timeless facet of the psychotherapeutic relationship which is impossible to describe, but refers to the spiritual dimension of the healing relationship (Clarkson, 1995)"

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66 To measure the presence and relative weight of these constructs research teams at the University of Pennsylvania developed the Penn Helping Scale (Alexander & Luborsky 1986) ; at Vanderbilt the Psychotherapy Process Scale and the Negative Indicators Scale (Suh, Strupp & O'Malley 1986) ; and at Simon Fraser University the Working Alliance Inventory (Horvath & Greenberg 1986). These projects all based their work on the Bordin s (1976) three-factor operational decimation of the helping therapeutic working alliance that cons i sted of interpersonal bond between the client and therapist This is transference/counter transference without a pathological implication Bordin further suggested the need for agreement between the client and therapist as to the goal of therapy and agreement as to the tasks required to accomplish this goal. From 1976 Bordin maintained that to be effective the therapeutic relationship must be collaborative not hierarchical. Measuring Therapy Outcome Outcome evaluation has evolved from early opinions of the therap i sts to complex testing using instruments including the MMPI (McCullough 1993 ) to semantic differential studies designed to cover all possible theories available and obfuscate the purpose to the measure to avoid contamination (Stiles 1980) to market driven consumer satisfaction surveys (Patterson & Leach 1987) Therapist opinion may be highly accurate or may be self serving in any given situation A structured form of therapist opinion has been developed and normed over four decades and five versions of the Diagnostic and Statistical Manual. (DSM). The Global Assessment ofFunctioning (GAF) (APA 1994) is the most widely used outcome measure because it is the Axis 5 measure required as part of the five-axis mental health diagnostic report. Its use has been increased by the demand of most HMO s and PPO s for use of the five-axis system

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67 The origin of the GAF is the Health Sickness Rating Scale (HSRS) developed in 1962 It consisted of thirty case studies and seven scales ability to function autonomously ," seriousness of symptoms ," "degree of discomfort ," "effect on environment ," utilization of abilities ," quality of interpersonal relationships ," and breadth and depth of interest. A single score results as is true for the GAF These scale concepts can still be identified in the descriptions of the levels of functioning in the GAF The Global Assessment Scale (GAS) was a simplified form of the HSRS and has a 9 correlation with the HSRS The GAS more closely resembles the GAF in that it no longer has scales or case studies The descriptions illustrate each 10-point range on a scale from Oto 100 The GAF was identical to the GAS except it had a range ofO to 90 in the DSM-ill-R, however the scale has been returned to 0-100 in the DSM-IV (McCullough 1993). Other recommended instruments to be included in a core battery'' are the Beck anxiety and depression inventories the Hamilton anxiety and depression rating scales the psychiatric status schedule the social adjustment scale the Health Sickness rating scale the MCMI the Wisconsin Personality Disorders Inventory and such These measures however are more appropriate to a clinical population that allows a statically significant range of change. Nations such as Australia and New Zealand who have social health care have conducted extensive outcome scale development and utilization studies (Eisen et al 1999, Preston 2000) While these instruments are much more conc i se and economical than the battery of tests recommended by McCullough, they are again more geared to the outcome of clinical populations Consumer satisfaction is a business and marketing concept, which seems to have entered the health care environment with managed health organizations Employee

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68 Assistance Programs (EAP), social work and rehabilitation counseling seem to be on the leading edge of development of these instruments, however, reliability and validity has not been rigorously demonstrated. The consumer satisfaction survey is, nonetheless, the most appropriate outcome measure for this study of undergraduate students presenting with developmental and growth issues. Attkisson et al (1982) developed a college student satisfaction form that was too specific in it items and too long (82 items) to be used in this study An outcome satisfaction questionnaire was developed for this study using the work Dansky, et al (1996) as a guideline. The items developed were submitted to a committee of experts ( e.g Delphi Method for evaluation and were used by counselors and students in a pilot study at a local community college. Counselors and students were asked to respond to each item based on their experience at the counseling center and to offer content, wording, and face value feedback regarding each item. The resulting instrument consisted of two forms, one for participants, and one for facilitators. The participant form had 12 items, seven Likert-like items about satisfaction with the personal growth sessions outcome, two Likert-like items assessing the participant's self perceived computer competence, and one Likert-like items eliciting the participants' predicted future uses of computer-mediated counseling. Two items were open-ended qualitative questions requesting the participants' opinions about the personal growth sessions The computer-mediated aspect was specifically targeted in the qualitative questions to allow the participant to appraise his or her experience regardless of assignment to conditions of the experiment. The facilitator version had similar session focused items but did not have the qualitative items, the computer competence items, or the predicted future use items.

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69 This information was collected in personal interviews with the facilitators after they had completed their all of their sessions with participants Application in this Study The goal of this study is to contribute meaningful research to under-gird and advise the developing phenomena of Internet counseling The foundation for good counseling has been developed over the past century and for good communication over the past many millennia. The advent of a new venue for communication and the willingness of mental health professional to move out into this venue should surprise no one As counselors boldly go where no one has gone before providing mental health services in cyberspace, research asks What is known about the new environment? What needs to be known? What risks can be anticipated? What risks cannot be anticipated? What known tools can be used as is? What needs to be retooled? What new tools need to be invented? No one study begin to answers do all that, of course The purpose of existing professional literature is to suggest answers or directions to answers for some of these questions It seems clear from the literature that a rich very human culture has developed on the Internet over the past 30 years, initiated by graduate students at MIT, Stanford and 7 other prominent universities, who were given carte blanc to "see what could be done with the new technology. Government initiates to provide health care to citizens in geographically remote areas and the commercial emergence of Internet use have paved the way for cyber-counseling. Cyber counseling appears to lend itself to brief therapy with non-crisis clients Several years of cyber counseling practice have created a need for research to determine the efficacy of cyber counseling and to suggest predictive criteria for screening potential clients for appropriateness for cyber counseling Many

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70 questions need to be explored. There are several technologies that can be used virtual reality, web-cam live transmissions, individual written messages (email), public written messages (bulletin boards), and live written messages (chat rooms). The Internet lends itself to group interaction, but individual intimacy is also well represented The scope of this study was confined to individual therapy in a live ( syn chronic) written format The individual differences the participant brings to the personal growth computer-mediated sessions were compared to those that they bring to traditional face-to-face sessions

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CHAPTER3 METHODOLOGY Statement of Purpose The purpose ofthis study is to examine the efficacy of Internet counseling Chat room counseling was compared with traditional face-to-face counseling Similarities and differences were measures for therapist-participant alliance and for outcome Four of the multitude of individual differences gender ethnicity personality and informa t ion processing, that each participant brings to the therapeutic setting, were measured to determine is any difference in impact can be discerned in the face-to-face or computer mediated condition. This chapter presents the research hypotheses dependent and independent variables sample population, procedures for training the facilitators procedures for the implementation of the personal growth sessions instrumentation, experimental conditions and assignment to conditions data collection and statically analysis Hypotheses The study will test the following null hypotheses : Ho1 : There is no significant difference in the client reported quality of the working alliance when counseling is delivered face-to-face or computer mediated regardless of gender ethnicity personality style learning st y le Ho2 : There is no significant difference in outcome efficacy when counseling is delivered face-to-face or computer-mediated regardless of gender ethnicity personality style or learning style Ho3a : There is no significant relationship between the client reported quality of the working alliance and gender in CM Counseling 71

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72 Ho3b: There is no significant relationship between in the outcome efficacy and gender in CM Counseling Ho3c : There is no significant relationship between the client reported quality of the working alliance and gender in F2F counseling Ho3d : There is no significant relationship between the outcome efficacy and gender in F2F Counseling Ho4a: There is no significant relationship between the client reported quality of the working alliance and ethnicity in CM Counseling Ho4b : There is no significant relationship between the client reported outcome satisfaction and ethnicity in CM Counseling Ho4c : There is no significant relationship between the client reported quality of the working alliance and ethnicity in F2F counseling Ho4d : There is no significant relationship between the outcome efficacy and race/ethnicity in F2F Counseling HoSa : There is no significant relationship between the client reported quality of the working alliance and visualizing learning style in CM Counseling HoSb : There is no significant relationship between the client reported outcome satisfaction and visualizing learning style CM Counseling HoSc : There is no significant relationship between the client reported quality of the working alliance and verbalizing learning style in F2F counseling HoSd : There is no significant relationship between the outcome efficacy and verbalizing learning style in F2F Counseling. Ho6a : There is no significant relationship between the client reported quality of the working alliance and introversion in CM Counseling Ho6b : There is no significant relationship between the client reported outcome satisfaction and introversion in CM Counseling. Ho6c: Th~re is no significant relationship between the client reported quality of the working alliance and extraversion in F2F counseling Ho6d : There is no significant relationship between the outcome efficacy and extraversion in F2F Counseling

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73 Descriptions of Variables The research design consists of random assignment of participants to one of two conditions. The conditions are face-to-face personal growth sessions and computer mediated chat room personal growth sessions. Because the participants were randomly assigned to one of the two conditions, post-test only were used to measure the variables. RO 3 face-to-face personal growth sessions Posttests RI 3 computer-mediated personal growth sessions Posttests The three sessions were conducted to facilitators who will work with an equal number of participants in each condition, that is, if a facilitator works with a total of 10 participants, he or she will conduct three sessions face-to-face with 5 participants, individually, and 5 sets of sessions via computer chat room. Ten graduate students representing a broad population of counselors (1 male, 9 females; 1 African American, 1 Hispanic; 3 licensed mental health counselors, 3 certified rehabilitation counselors; age range 23 to 56), from counselor education and rehabilitation counseling were hired and trained to conduct the personal growth sessions. The participants received extra credits in their counselor education interpersonal skills, substance abuse, or stress management classes, at the discretion of their instructor The quality of the working alliance and the outcome satisfaction were measured to evaluate and compare the counseling experience in the two conditions. The individual differences that participants bring to the experience were measured to determine if any and which differences might predict better success with one condition or the other. For example, do introverted participants do better in one condition than they do in the other? Do African American participants benefit more from one condition than they do in the other? Is there any difference in the working alliance developed by participants with a verbal learning style in one condition versus the other?

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74 This could be a valuable contribution to pre-screening criteria for clients who apply for computer-mediated counseling Dependent Variables There are two sets of dependent variables in this study the participant perceived quality of the working alliance during counseling and the participant's report of outcome satisfaction with the personal growth counseling received plus the facilitators opinions on the same concepts The working alliance is a process construct thought to describe the counselor-client relationship as it pertains to providing a helping environment for therapy to occur. It was measured with the Working Alliance Inventory The clients' outcome satisfaction is a product construct that taps the results or benefits gained in therapy It was measured with Outcome Satisfaction Questionnaire developed for this study and described above Independent Variables The independent variables race/ethnicity, gender learning style and introversion/extroversion were investigated in this study. Ethnicity is an important variable because while the Internet makes democracy -the free exchange of information and universal individual input more available to many there is realistic concern that some are marginalized because of limited access to technological resources and strategically administered corporate or organization control of resources (Mantovani 2001 p 51). Gender has been suggested as a differential variable in cyberspace Men have long dominated math, science and engineering careers Internet access and savvy have grown out of training familiarity and experience with computer technology Therefore there is concern that women have not had the exposure to computer technology to make

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75 this form of communication and counseling available to them There is also concern that as women are thought to be more relational in their orientation while men are more analytical computer-mediated counseling may disadvantage female clients Learning styles that favor visual learning written expressiveness and/or individual work may be more adaptive to Internet counseling while verbal learning oral expressiveness and/or group work may be disadvantaged in a computer-mediated env i ronment. Personality type likewise may predispose some clients to more comfort and effectiveness using computer-mediated counseling and disadvantage others The personality trait introversion/extroversion was an independent variable to determine if introversion is predictive of great outcome satisfactions than extroversion Population The population was a southern university undergraduate population and from a community college in the same locale with an age median of 20 This population is thought to be representative of computer users who use computers for social as well as technical purposes have grown up in a technological age and are of the age and social class most representative of computer users. Undergraduates volunteered for the study after hearing a presentation in their classroom, completing a contact sheet with demographic information, and signing an informed consent. They were provided with a duplicate of the informed consent form and were randomly assigned to personal growth sessions in either a face-to-face or computer-mediated counseling condition Participants were enrolled in stress management substance abuse or interpersonal skill classes in the department of counsel education or in the student development classes at the community college Students (N = 123 ; M = 29 ; F = 94) were contacted by their facilitator and

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76 scheduled for sessions Upon the completion of three personal growth sessions, the participant completed the MBTI, the CITE, the WAI ( c) and the OSQ (p) in an encrypted website monitored by a survey technician available in chat room S of the site who was trained to answer any questions about the mechanics of completing the instruments that arose The facilitator, who was not the monitor, completed the WAI (t) and the OSQ (f). Sampling Procedures Volunteers were recruited from the population of students enrolled in undergraduate counseling education classes in interpersonal skills and stress management. Most participants received a small amount (no more than 2% of grade) of class credit for participation and three sessions of personal growth guidance. Participants were quasi-randomly assigned to the twelve facilitators and were randomly assigned to face-to-face or computer-mediated study conditions Exceptions were made to random assignment to facilitators if the facilitator knew the participant or if the facilitator and participant were unable to find a mutually convenient time to meet The facilitator each conducted an equal number of face-to-face and computer-mediated sessions. Pre induction paperwork included an informed consent, assurance that volunteers are at least 18 years of age, and provision of a code for confidential contact, a phone number, and/or an email address. All volunteers had adequate computer ability so that they could be randomly assigned to conditions. The university requires these skills of undergraduates and requires all undergraduates to own or have access to a computer with sufficient application software to participate in this study. The computer-mediated sessions were conducted in the university electronic learning gateway system WebCT. Many classes are offered or supplemented through this system so all students can be expected to learn how to use it at some point in their undergraduate career. The university has a computer

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77 help desk for students who have any difficulty accessing or using the system and participants were notified of these services Midway through the study, the University moved WebCT to an authenticated server that required identification at log on However, the university maintained the original server for studies such as this that require anonymous or coded logon This did not negatively affect the study in any way because site appearance remained the same to the facilitators and because the participants had never seen the other system When participants navigated to the WebCT home page they found this among other studies listed individually with a link to the older server ( e g Participants in the Groble dissertation study click here). The one possible confound was that the new server relieved the lag time problem encountered in the spring term when the old server was overloaded Facilitators either did not notice or did not mention any difference The lag was inconsistent in the spring depending on the time of day of appointments. The lag occurred when the system was experiencing heavy use throughout the university The facilitators may have adjusted their scheduling to minimize this problem. Data Collection Procedures The principal researcher established a dedicated, password secured web site with a text-talk ( chat room) application for use by facilitators who conducted the personal growth sessions and data collection Recruitment was conducted in the source classrooms during regularly scheduled class with the instructor s permission to discuss the study, explain the participants rights to withdraw without harm, obtained informed consent and contact information The principal researcher did not access to the web site once the study begins and each assistant was instructed how to secure his or her

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78 participants' sessions Sessions were downloaded with the permission of the participant for further research analysis outside the scope of this study. Nine graduate students and one recent graduate from the Department of Counselor Education or the Department of Rehabilitation Counseling were trained in the study protocol, study logistics, cognitive behavior therapy principles, WebCT use, Internet Resources for clients, and research on the typical personal growth issues of undergraduates. All trainings were conducted in person by the principal investigator who prepared the extensive, detailed manual each facilitator received Additional computer specific training was provided by the principal investigator and by University personnel familiar with the WebCT resources The principal investigator coordinated with the instructors for the interpersonal communications, substance abuse, student development, and stress management classes to present the study during class early in the term and recruit participants. Participants were contacted individually, randomly assigning to one of the two conditions, scheduled for first session, given any direction needed for finding the counseling lab or WEBCT chat room The principal investigator was available via beeper during any sessions to insure the safety of participant and availability to the graduate student facilitators Facilitators received weekly supervision in accordance with their program requirements (practicum, research, registered intern, and such) and project design The participants presented genuine concerns common to college undergraduates such as but not limited to adjustment to college life, time management, study habits, career indecision, roommate relations, and so forth The facilitator contacted each participant to set up the first meeting He or she gave directions for participation When

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79 the participant was assigned to the face-to-face condition, the facilitator ensured that the participant understood where and when to meet with the facilitator When the participant was assigned to the computer-mediated condition, the facilitator provided direction for the participant to log on to the chat room at the appropriate time and ensured that the participant understood how to log on to the system and navigate to the chat session space The logistic of the experiment detailed session outlines record keeping forms and the required readings list are located in the facilitators training manual in Appendix B Instrumentation Working Alliance Inventory (Client) The Working Alliance Inventory Client (YI AI c) is a 36 item developed by Horvath (1984b 1986) to be used early in the relationships between the 3 rd and 5 th session It was administered at the end of the 3 rd session for purposes of this research. The Working Alliance Inventory targets the client-therapist relationship in a pan theoretical approach (Horvath et al. 1993 p 255) It was designed to be counseling theory neutral while operationalizing Bordin' s description of the three factor working alliance tasks goals and bond (Horvath & Greenberg 1986). The WAI consists of 36 items, 12 relating to each of the factors of the working alliance The WAI client version has a Hoyt's estimate of reliability of 88 for the goal and task subscales a Hoyt s estimate of reliability of .85 for the bond subscale and a Cronbach s alpha of 93 for the composite (Horvath & Greenberg 1986) Items are rated on a Likert-like scale from one being never to seven being always Sample items (Horvath, 1984b) "I find what I am doing in therapy confusing (Tasks) I am worried about he outcome of these sessions ( Goals) (name of counselor) and I understand each other ." (Bond)

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80 The advantage of these measure are that they have forms for both the participant and the therapist providing the opportunity to view the therapeutic relationship through both lenses. The forms are attractive, well researched and easy to understand and complete with a minimum of time and effort on the part of the participant. The questions are non-threatening and non-intrusive while tapping all three aspects of the working relationship defined by Bordin and fundamental to all therapeutic relationship instruments examined Working Alliance Inventory (Therapist) The Working Alliance Inventory Form Tis the therapist version that assesses the therapist view of the working alliance across all three components of bond, task agreement and goal agreement. Sample items (Horvath, 1984a) "I feel uncomfortable with _____ (bond) My client and I both feel confident about the usefulness of our current activity in therapy. (tasks) ____ and I have a common perception of her/his goals (goals) Outcome Satisfaction Questionnaire An outcome satisfaction questionnaire was developed for this study because outcome measure reviewed in the literature emphasized medical diagnosis and symptomatology or were site specific dealing with the mechanics of scheduling appointments and locating offices Items for this outcome measure were written by the principle investigator or adapted from existing instrument where applicable. A committee of experts reviewed the potential items A pilot study of the instrument was conducted at a local community college to gather feedback from students receiving counseling and from counselors regarding item wording, appropriateness and face value. Information from the committee and from the community college study were

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81 implemented into the final 12 item form developed for participants and 7 item form developed for facilitators The facilitator form did not include qualitative questions found on the participant form Students rated their perception of their computer skills and their likelihood of seeking Internet counseling should they seek counseling in the future. They answered open-ended questions about what they least liked about computer-mediated communication as they had experienced it in this study and were encouraged to offer suggestions, comments and ideas about the Internet interaction study Facilitators were trained in adequate computer skills as needed before beginning their work on this project and were individually debriefed about the other points in end of study interviews Myers Briggs Type Indicator Form M (MBTD The MBTI is arguably the most researched and most widely used personality instrument. The Singer-Loomis Type Deployment Instrument (Singer 1996) and Keirsey Type Indicator (1984/1996) are similar Jungian theory based instruments but less researched and less often applied. The Keirsey Type Indicator is readily available on the Internet, although no longer free The Singer-Loomis is still considered to be a research tool, and as such not used in applied setting such as business, counseling, and career development. The strength of the Singer-Loomis is that it is built upon a dynamic theory of personality growth and change rather than what has been seen as the rather static typing of the MBTI The MBTI however was used in this study because the introversion/extroversion scale has consistently been found to have predictive and discriminative value The Keirsey and Singer Loomis blend the four scales while the MBTI is more consistent with Jung's theory that introversion/extroversion is a attitude, while thinking/feeling and intuition/ sensing are traits It is the introversion/extroversion

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82 scale of the MBTI that was used in this study. Eysenck developed an introversion/extroversion scale as part of his three factors biologically based formulation of personality ; however, it is more applicable to a clinical population than the population of this study. The MBTI is statistically sound The phi coefficient for reliability ranges from 55 to .65 for the introversion/extroversion dimensions; .64 to .53 for the sensing/intuiting dimension; .43 to 75 for the thinking/feeling dimension and .58 to 84 for the judging/perceiving dimension The tetrachoric coefficients are higher, 70 to 81 for 1/E ; 82 to 92 for SIN ; 66 to 90 for T/F and 76 to 84 for J/P Reliability is found to increase with the population s age and intelligence When the data were converted to continuous scores the reliability estimates are more consistent at .76 to .821/E ; 75 to 87 SIN; /69 to 86 T/F and 80 to 84 J/P (Willis, 1984) Table I I. I (Myers & Mccaulley 1993, pp 177-206) describes the validity studies correlations between the MBTI and the Adjective Check List by scales the California Psychological Inventory by scales, the Comrey Personality Scales, by scales the Edwards Personality Preference Survey by scales, the Emotions Profile Index by scales, the Eysenck Personality Questionnaires by scales, the Maudsley Personality Inventory by scales, the Jungian Type Survey by scales, the Minnesota Multiphasic Personality Inventory by validity and clinical scales, the Omnibus Personality Inventory by scales the Personality Research Inventory by scales, the Stein Self Description Questionnaire by scales, the Brown Self Report inventory by scales the Sixteen Personality Factor Questionnaire by scales and by second order traits, the State-Trait Anxiety Inventory by state and trait, the Study of Values by scales, The Rokeasch Dogmatism Scales, the Opinion, Attitude and Interest Scale by scales the

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83 Kuder Occupational Interest Survey by college major and occupational scales, the Strong-Campbell Interest Inventory (now known as the Strong Interest Inventory) by occupational themes, the Kolb Learning Style Inventory by scales, the Science Research Temperaments Scale, the Watson Glaser Critical Thinking Appraisal, and lesser known instruments including the Conflict Management, the Harbaugh (W)holistic Scales, the Internal-External Locus of Control and the Intolerance of Ambiguity. The body of work establishes the MBTI construct validity, divergent and convergent validity Center for Innovating Teaching Experiences Learning Styles Inventory (CITE) The Center for Innovative Teaching Experience, Murdock Teacher Center, Wichita Kansas School District developed the Learning Style Inventory most prevalently used in education today The CITE Learning Style Instrument is composed of 45 items that the respondent scores 4, 3, 2, or 1 A score of 4 on an item means that the respondent feels the statement is "most like me" while a score of 1 indicates that the statement is "least like me". Results were calculated for nine subscales visual language, visual numerical, auditory language, auditory numerical, kinesthetic-tactile social-individual, social-group, expressiveness-oral and expressiveness-written (Babich et al., 1976) For the purposes of this study, the visual numerical and auditory numerical are thought to be irrelevant to the counseling context but were analyzed in case they tap symbolic language Items were scored for each category and significance or "major learning style" is determined by a cut score of33 on any scale. The split-half reliabilities were .6 or better for eighty-five percent of the constructs Sample items (Babich et al ., 1976) "I remember things I hear better than I read" (Auditory) "I would rather read a story than listen to it read." (Visual)

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84 Richardson developed a visualize verbalizer scale ; however it has not been used outside research and is thought to be less applicable to this study than the visual and auditory scales of the CITE that has been widely used with adult populations and normed to the same population as this study Richardson s scale was normed to a middle school population and the norming sample was small Demographics Participants were asked to indicate their age gender and race or races. It seems unlikely that the population of convenience have have any significant variance in age or gender but these questions were asked in case the perception of homogeneousness i s erroneous The age question was not r elevant however the gender question returned essential data. The ethnic composition of the population of this study was expected to be diverse and thought have significance in the working alliance and outcome of the face-to face or computer-mediated sessions Data Analyses Procedures Data were analyzed using SPSS 11.0 ANOVA procedures were used t o analyze the data because this procedure is sensitive to relationships between the independent variables gender ethnicity learning style and personality traits and the dependent measures. Means and standard deviation were computed for all significant main effects and interactions to evaluate the efficacy of computer-mediated counseling compared to face-to-face counseling in the process dimension, working alliance and the outcome dimension efficacy.

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CHAPTER4 DATA ANALYSIS The purpose ofthis study was to evaluate the efficacy of brief, cognitive behavioral therapy provided on the Internet in real time chat room modality The study compared two sets of participants. Participants in one set met with the protocol trained graduate counseling student facilitators face-to-face Participants in the other set met with protocol-trained graduate counseling student facilitators via the Internet in a University of Florida, WebCT, classroom chat room. All participants and all facilitators completed the dependent variable surveys via the Internet through the WebCT evaluation utility that provided anonymity for surveys. The chat room was set up so that participants entered by code rather than by name Descriptive Statistics for Dependent Measures This study used four instruments as dependent variables. Two forms of The Working Alliance Inventory were used, form c for clients and form t for therapist. The Working Alliance Inventory provided a total score as well as three sub scores per version. The student version of the Outcome Satisfaction Questionnaire measure provided three scores and qualitative responses for future analysis. Common to both the participant form and facilitator form was the outcome satisfaction scale In addition, participants estimated their computer use skill on a Likert-like scale and predicted the likelihood that they would choose computer-mediated counseling in the future. High scores indicate positive responses for the WAI while low scores report favorably on the OSQ. That is, the closer a participant's score is to the minimum for outcome satisfaction, predicted 85

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86 future use, and computer skill the greater their positive response The closer a person's score is on any of the WAI versions or scales is to the maximum, the more positive die response. The data was evaluated using analyses of variance (ANOVA), that require that the independent variable or factor consist of two or more levels and that those levels cover all possible levels of interest to the researcher (e g male, female). The levels were qualitative (e g., face-to-face, computer-mediated personal growth sessions) or quantitative (e g ., MBTI introversion/extraversion). The participant endorsed one and only one level of each factor Each independent variable in this study met the criteria The critical F value to disprove the Null hypothesis at the 05 confidence level is F (aitical 1 123) = 3 92 The independent factors or variables were condition to which the participant was randomly assigned, ethnicity, gender, academic learning style, personality attitude, temperament learning style. Table 1 depicts the meaningful descriptive statistics for the independent variables gender, ethnicity, academic learning style, trait learning style, and attitude and for the dependent variables working alliance, by scales, outcome satisfaction, predicted future use, and computer/Internet skill level. The table is organized by experimental conditions, face-to-face and computer-mediated treatments. Table 2 presents the factors and levels of each factor used in the analyses of variance. Participant Dependent Variables Analysis To evaluate outcome efficacy, participants were asked to evaluate the quality of their experience in the face-to-face or computer-mediated conditions and their outcome satisfaction They were asked to predict if they thought they would be likely to use computer-mediated counseling in the future They were asked to describe their comfort

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87 and skill level with using a computer and using the Internet. To allow the researcher to examine the process efficacy of these sessions in the two conditions participants answered questions about their total evaluation of the working alliance they co-created with their facilitator Table I Descriptive Statistics for Dependent Variables by Conditions Variables N Minimum Maximum Mean Std. Deviation FACE-TO-FACE CONDITION W Al Task (client) 59 7 44 32.88 8 748 W Al Bond (client) 59 14 60 46.00 10.609 WAI Goal (client) 59 2 36 25 05 8.330 WAI Total (client) 59 23 140 103 93 24 676 Satisfaction (participant) 59 7 27 12.64 4.877 Computer Skill participant) 59 2 7 4.00 1.218 Predicted future use (participant) 59 0 3 95 .705 WAI Task (therapist) 58 -4 42 27 74 9 049 WAI Bond (therapist) 58 30 60 49.31 8 217 WAI Goal (therapist) 58 -14 33 18.74 10.597 WAI Total (therapist) 58 17 127 95.79 25 360 Satisfaction (therapist) 58 8 23 15 83 3 738 COMPUTER-MEDIATED CONDmON WAI Task (client) 64 11 44 31.27 8.016 WAI Bond (client) 63 23 60 45 67 8 160 WAI Goal ( client) 63 3 36 24.13 7.722 WAI Total (client) 63 52 137 101 22 21.372 Satisfaction (participant) 63 7 24 13 76 4 294 Computer Skill participant) 63 2 10 4 27 1.096 Predicted future use (participant) 63 0 2 70 .687 WAI Task (therapist) 63 2 44 28.65 9.172 WAI Bond (therapist) 63 34 60 48.86 7.118 WAI Goal (therapist) 63 -8 36 19 57 10.171 WAI Total (therapist) 63 29 137 96.84 24 022 Satisfaction (therapist) 64 7 25 16 42 4 227 The inventory subscales indicated the strength of the personal relationship (bond) the mutual creations of tasks, which would lead to accomplishing the goal set for these

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88 sessions, and ability to delimit, define and specify a goal. The results of their responses are discussed in the text below and displayed in tables three through twenty-four below. Table 2 : Independent Variables, Levels of Each Variable and Number of Participants at Each Level Factors Levels Number of participants Conditions Face-to-face 58 Computer-mediated 64 Gender Male 29 Female 94 Ethnicity Caucasian 94 African American 12 Hispanic 17 Academic Learning Styles Visual learners 30 Verbal learners 93 Introversion/ Extraversion Extraverts 88 Introverts 35 Temperament Learning Styles Intuitive Thinking (NT) 18 Intuitive Feeling (NF) 53 Sensing Judging (SJ) 41 Sensing Perceiving (SP) 11 Predicted future use (participant) Participants were asked to predict the likelihood that they would choose computer-mediated counseling should they decide to seek out counseling of their own volition rather than being randomly assigned to a condition as in the present study. Table 3 shows the results of the ANOV A. The main effect, learning style, was significant (F = 4.25, p = .042) but no interactions between face-to-face or computer-mediated counseling and the independent variables were significant.

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89 To further analyze the relationship between academic learning style preference and predicted use follow up tests were applied For this variable the lower value indicates preference and the higher the score indicates negative responses Table 3 Source Table Dependent Variable-participant predicted future use of computer-mediated counseling Sources of Variance Corrected Model Intercept Condition Gender Ethnicity 1.11111. I -i I III Introversion/Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total Type m Sum df Mean F Sig of Squares Square 7 673 17 .451 897 580 15 869 1 15 869 31.520 000 .280 1 280 556 .457 319 1 319 633.428 6 576E-02 2 3 288E-02 065 937 i i f.11 1 : 1 l; : JAI l & lli i ; P:11 8 222E-04 1 8 222E-04 002 968 1.139 3 380 .754 522 2.739E-02 1 2 739E-02 054 816 .319 2 159 317 729 113 1 113 224 637 606 1 606 1. 204 275 309 3 103 205 893 52 360 104 503 142 000 122 60.033 121 Table 4 displays the resulting means and standard deviation Those who use a visual learning style predicted that they wou l d be more likely to seek computer-mediated counseling should they need counseling in the future (M = 56 SD= 58) consistent with the study hypothesis that visualizers would be more likely to seek computer-mediated counseling than verbal or auditory learners (M = .89 SD= 72) Table 4 Means and Standard Deviation for Significant Main Effect Academic Learning Styles ; Dependent Variable-Predicted Future Computer-Mediated Counseling Use Academic Learning Style Preference Visual learners Verbal learners Mean 56 89 Std Deviation 583 720

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90 Level of Computer/Internet Skill Academic learning style produced a significant main effect when participants were asked to describe their level of comfort using computer and the Internet and their computer and Internet skill level (F = 3 95 p = .049) Table 5 depicts all of the results of the analysis for this dependent variable. The lower scores indicated greater comfort and skill while the higher scores indicate less comfort Participants who endorsed the visual learning style preference estimated their computer skill to be more limited (M = 4 56 SD = 1 53) than did participants who endorsed the verbalizer or auditory learning style preference (M = 4 03 SD= 1 03) contrary to expectation Verbalizers had better skills and greater comfort but visualizers predicted greater future use. Table 5 Source table for dependent variable -computer/internet skill level (participant) Type ill Sum df Mean F Sig. Sources of Variance Corrected Model Intercept Condition Gender Ethnicity i il ii!Pi: -i ii lli Introversion/ Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Leaming Style Error Total of Squares Square 28.445 17 1.673 1.297 209 532.841 1 532 841412.975 000 804 1 804 623 .432 2.929 1 2 929 2.270 .135 4.740 2 2 370 1.837 164 1 1: Jtl : 1. : : l~i. : ffli l ~ III I ffl l 5 866E-02 1 5 866E-02 045 832 4.434 3 1.478 1.145 334 7 398E-02 1 7 398E-02 057 .811 876 2 .438 340 713 2.417 1 2.417 1.873 174 282 1 282 218 641 4 021 3 1.340 1.039 379 134 186 104 1.290 2253 000 122 Corrected Total 162 631 121 a R Squared= .175 (Adjusted R Squared= 040)

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91 This result is interesting and should be interpreted with caution because it is likely that the instrument eliciting skills and comfort may need to be enhanced for greater accuracy (see discussion, chapter 5) .. Table 6 Means and Standard Deviation -Dependent Variable, level of computer/ Internet skill and comfort (participant), Independent Variable, academic learning style Academic Learning Style Visualizer Verbalizer Outcome Satisfaction (Participant) Mean 4.56 4 03 Std Deviation 1. 530 1. 025 Participants' responses about their outcome satisfaction did not produce any significant main effect or interaction in the outcome satisfaction measure (Table 7) Table 7 Source table for dependent variable-outcome satisfaction (participant) Sources of Variance Corrected Model Intercept Condition Gender Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total TypeIDSum df of Squares 356 389 17 5308 807 16.177 25 548 84 967 7 598 9 763 59 018 31.766 1 1 1 2 1 1 3 1 Mean F Sig. Square 20.964 989 .476 5308.807 250 434 000 16.177 .763 384 25 548 1.205 275 42 484 2.004 140 7 598 358 .551 9 763 .461 499 19 673 928 430 31.766 1.499 224 29 799 2 14 899 703 .498 003 .960 5 441E-02 1 5 441E-02 24 616 1 24.616 24.496 3 8.165 2204 636 104 21.198 23887 000 122 1.161 .284 .385 764 Corrected Total 2561. 025 121 a R Squared= 167 (Adjusted R Squared= 021) The most positive outcome satisfaction score possible was seven The score indicating the greatest possible dissatisfaction with the experience was twenty-eight. The observed

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92 score range was from seven to twenty-seven in the face-to-face condition (M = 12 64, SD = 4.88) and from seven to twenty-four in the computer-mediated condition (M = 13 76, SD = 4 29) This does not mean that the participants were dissatisfied with their experience but that the measure of satisfaction did not detect any independent variables that influenced satisfaction. In other words, the participants were equally satisfied in either experimental condition and regardless of individual differences Working Alliance Inventory Total (Client) The Working Alliance Inventory provided four measures a total rating, and three subscale scores. The subscales measured bond similar to rapport, agreement on goal to be achieved in counseling, and agreement oftask(s) to be developed to accomplish the agreed upon goal of this episode of brief counseling. There were no significant main effects or interactions for the dependent variable WAI (c) total score (Table 8) Table 8. Source table for dependent variable WAI (c) Total score Sources of Variance Corrected Model Type Ill Sum df of Squares 9574.904 19 Mean Square 503.942 F Sig . 947 .528 Intercept 216085 736 1216085.736 406 031.000 Condition 521.780 1 521.780 980.324 Gender 153.238 1 153 238 288 593 Ethnicity 817.424 2 408.712 768 467 AcademicLearningStyle 1251.056 2 625.528 1.175 313 Introversion/Extraversion 109.434 1 109.434 206 651 Temperament Learning Style 1433.145 3 477.715 898 445 Condition by Gender 817 339 1 817 339 1.536 218 Condition by Ethnicity 833.397 2 416 698 783 .460 Condition by Academic Learning Style 36.584 2 18.292 .034 966 Condition by Introversion/ Extraversion 206 308 1 206.308 388 535 ConditionbyTemperamentLearningStyle 2112.052 3 704 017 1.323 271 Error 54618.875 104 525 181 Total 1346441.000 122 Corrected Total 63858.369 121 a R Squared= 126 (Adjusted R Squared= 026)

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93 Working Alliance Inventory Bond (Client) There were no significant main effects or interactions for the dependent variable working alliance (c) bond,(Table 9) Working Alliance Inventory Task (Client) There were no significant main effects for independent variables by WAI ( c) task sub scale (Table 10) however there was a significant interaction between condition and gender (F= 3 92 p = .05). Unlike the scores on the Outcome Satisfaction Questionnaire, where lower scores were more positive than higher scores, the Working Alliance Inventory is scored so that the higher the score the great the positive response Table 11 shows the means and standard deviation for gender by condition Table 9 Source table for dependent variable-WAI (c) Bond sub score Sources of Variance Corrected Model Intercept Condition Gender Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total Type ID Sum df of Squares Mean Square F Sig 1550.132 43334 786 2 012E-04 9 003 312 180 180.325 6 755 461.944 7.433 232 154 18 941 .261 19 81.586 914 568 1 43334 786485 237 000 1 2.012E-04 000 999 1 9 003 101 752 2 156.090 1.748.179 2 90 162 1.010 368 1 6 755 076 .784 3 153 981 1.724.167 1 7.433 083 774 2 116 077 1.300 .277 2 9.471 .106 .899 1 .261 003 957 358 995 3 119 665 89 306 1 340 266 9109.254 102 266883 000 122 10659.385 121 a R Squared= 123 (Adjusted R Squared = 030) Male participants reported greater task development congruity (M = 34 14 SD = 8 32) with their facilitator in the face to face than in the computer-mediated sessions (M =

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94 27.00, SD =8.63), by almost one standard deviation. This suggests that males were better able to define tasks needed to achieve their personal growth goals in the face-to-face condition than in the computer-mediated condition, a finding contrary to expectations Female participants seem to develop tasks in collaboration with their facilitator equally well in either condition. (M = 23.49, SD= 8.93~ M = 23.57, DS = 7.43) Table 10 Source table for dependent variable -Working Alliance Inventory ( c) Task sub score Sources of Variance Corrected Model Intercept Condition Gender Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style lii~Uiii. i! li :! iili Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total Type ill Sum df of Squares Mean Square F Sig. 1498.521 21142 080 158 147 20 758 60.911 105 094 114.795 26 789 litt :.: 1 : 11 130.877 1.544 65 358 19 78.870 1.158 .308 1 21142.080310.493 .000 1 158 147 2.323 131 1 20.758 .305 .582 2 30.455 .447 .641 2 52 547 772 .465 1 114.795 1.686 .197 3 8.930 131 .941 m lii !l: i; I I Rl.i Ilil 2 65.438 961 .386 2 .772 011 .989 1 65.358 960 .330 294.627 3 6945.380 102 134398 000 122 8443.902 121 98 209 68.092 1.442 .235 a R Squared= .177 (Adjusted R Squared= .024) Table 11. Means and Standard Deviation-Dependent Variable, WAI (c) task sub score Independent Variable, Gender Face-to-face Computer-mediated Male M=34.14 S.D = 8 32 M =27.00 S.D = 8 63 Female M = 32.49 S.D = 8 93 M = 32.57 S.D = 7.43

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95 Working Alliance Inventory client subscale goal There were no significant main effects or interactions for the dependent variable working alliance total participant version Table 12 lists relevant statistics. Table 12. Source table for dependent variable-WAI (c) Goal sub score Sources of Variance Type ID Sum df Mean F Sig of Sguares Sguare Corrected Model 1176 827 19 61.938 961 512 Intercept 12382 566 1 12382.566192 211 000 Condition 105.700 1 105.700 1.641 203 Gender 23 255 1 23 255 361 549 Ethnicity 14 336 2 7 168 111 895 Academic Learning Style 161.415 2 80 707 1 253 290 Introversion/ Extraversion 5 503 1 5 503 085 771 Temperament Learning Style 231.919 3 77 306 1.200 314 Condition by Gender 90 501 1 90 501 1.405 239 Condition by Ethnicity 102 026 2 51.013 792 .456 Condition by Academic Learning Style 6 826 2 3.413 053 948 Condition by Introversion/ Extraversion 33 275 1 33 275 517 .474 Condition by Temperament Learning Style 208 935 3 69 645 1.081 .361 Error 6571.010 102 64.422 Total 81420 000 122 Corrected Total 7747 836 121 R Squared= .152 (Adjusted R Squared= 006) Facilitator Dependent Variable Analysis Facilitators completed the facilitator's version of the Working Alliance Inventory and of the Outcome Satisfaction Questionnaire Unlike participants the facilitators were not asked to report their predicted future use and computer/Internet skill and comfort levels in these surveys Those factors were discussed at length in individual debriefing sessions with each facilitator but do not appear in these analyses.

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96 Outcome Satisfaction Facilitator scores on the Outcome Satisfaction measure demonstrated statistically significant for the main effect gender so follow up analysis was conducted Table 1 0a displays the ANOV A outcome while Table 1 Ob presents the means and standard deviation for the significant main effect Facilitators reported that female participants experienced greater overall outcome satisfaction (mean 15 55 standard deviation 3 7) with their personal growth sessions than did male participants (mean 18 03 standard deviation 4.4) There was no significant interaction by condition suggesting that this facilitator perceived gender related outcome satisfaction did not differ by condition Facilitators perceived that female participants experienced greater outcome satisfaction with their personal growth sessions However there was no significant difference in participants' report of outcome satisfaction (see Table 5) Table 13. Source table for dependent variable Outcome Satisfaction (facilitator) Sources of Variance Corrected Model Intercept Condition Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total Type ID Sum of Squares df Mean Square F Sig 338 795 19 6252 829 1 3.410 1 \ l~lt:rr+ l iI 793 2 22 924 2 1.074E-02 1 23.115 3 11.576 1 13.402 2 20 864 2 27 036 1 65 180 3 1563 530 100 32911.000 120 1902 325 119 17 831 1.140 324 6252 829399.917 000 3.410 J!l~lJfil~~ 397 11.462 1.074E-02 7.705 11.576 6.701 10.432 27 036 21.727 15 635 218 642 lt:t;J;:1 @II .025 975 733 .483 001 979 .493 688 740 392 .429 .653 667 .515 1.729 192 1 390 .250

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97 Follow up analyses were conducted (Table 14) and found that facilitators felt that male participants experienced less outcome satisfaction (M = 18 03, SD =4 39) than did female participants (M = 15 55, SD= 3 70). Table 14 Means and Standard Deviation for gender variable Dependent Variable: Facilitator perceived outcome satisfaction GENDER Male Female Working Alliance Inventory total (therapist) Mean 18 03 15 55 Std. Deviation 4.387 3 696 Analysis of variance for dependent variable, working alliance inventory (t) total score, a composite of bond, task, and goal, produced significant the main effects for gender (F= 7 ll), p = .009) Table 15. Source ofVariance Table-Dependent Variable : Working Alliance Inventory total (therapist) Sources of Variance Type III Sum df Mean F of Squares Square Corrected Model 11899.169 17 699.951 1.190 Intercept 223760.842 1 223760.842 380.508 Condition 1812.589 1 1812.589 3.082 f :; .. ; lll&ffl Ill Ethnicity 268.679 2 134.339 .228 Academic Learning Style 20 833 1 20.833 .035 Introversion/ Extraversion 260.169 1 260.169 .442 Temperament Learning Style 682.333 3 227 444 387 Condition by Gender 1660.391 1 1660.391 2.824 Condition by Ethnicity 552.180 2 276.090 .469 Condition by Academic Learning Style 336.556 1 336.556 .572 Condition by Introversion/ Extraversion .646 1 .646 .001 Condition by Temperament Learning Style 1337.318 3 445.773 .758 Error 60569.938103 588.058 Total 1195491.000121 Corrected Total 72469.107120 Sig. .286 .000 .082 IR .796 .851 .507 .763 .096 .627 .451 974 520

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98 Working Alliance Inventory Bond (therapist) Table 17 shows that the gender variable produced a significant main effect in the facilitator scores for bond (F = 9 97,p = .002). Gender by condition was a significant interaction in the WAI (t) task sub score (F = 7.33, p = .008). The significant interaction between gender and condition in the facilitator version is on the sub scale bond. The Mean and Standard Deviation for the gender main effect is not reported because it is superceded by the significant gender by condition interaction presented in Table 18 Facilitators recognized a stronger sense of rapport on bond with female participants than they did with male participants Since the participants, (Table 7), did not indicate any significance in the strength of bond developed it may be that the female participants were better able to communicate the sense of bond to their facilitator even though male participants seem to have experienced a similar level of bond Table 16: Means and Standard Deviation for Main Effect Gender-Dependent Variable: Working Alliance Inventory (t) total Gender Male Female Mean 83.83 100.28 Std Deviation 34 118 19 303 The interaction of gender by condition an important finding in this study that seeks to identify potential sources of individual differences that may impact the value of computer-mediated counseling and may be used as a screening factor It would appear that male participants were better able to develop and communicate that development of rapport with their facilitator in the computer-mediated condition (M = 49.33, SD= 7.64) than in the face-to-face condition (M = 42.86, SD= 8 51), while female participants were

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99 almost equally able to develop or communicate the development in either condition This is consistent with the study hypotheses Table 17 : Source table for dependent variable Working Alliance Inventory bond (t) Sources of Variance Type Ill Sum of df Mean Square F Sig. Squares Corrected Model Intercept Condition 1251.611 17 73.624 1 320 195 63658.408 22.037 ii ~ 49.859 1 63658 4081141.364 000 1 22.037 395 .531 ma11 1 : 1 ~ 1!1. 1 10 ~ Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total a R Squared = .179 (Adjusted R Squared = 043) .181 29.460 17.346 f9B J RJ.tJ. 97.366 54 961 67 525 54.236 5744.720 298400.000 6996 331 2 1 1 3 1 : 2 1 1 3 103 121 120 24 930 447 181 003 29 460 528 5.782 104 IM J B ~A ~ af 48.683 873 54.961 985 67 525 1 211 18 079 .324 55.774 Table 18 Mean and standard deviation for gender by condition interaction Dependent Variable: Working Alliance Inventory (t) bond Male Face to Face Computer Mediated Mean= 42.86 s d = 8 51 Mean=49 33 s d = 7 64 Working Alliance Inventory Task (therapist) Female Mean= 51.66 s d = 6.69 Mean=48 69 s d = 7 27 Analysis of the WAI (t) task sub score resulted in two significant main effects condition (F = 4 81 p = 03) and gender (F = 5 87 p = .02) Facilitators reported more collaborative task development with female participants than they did with male 641 955 469 .958 i .I .421 .323 .274 .808

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100 participants. Note that the participants did not indicate any significant main effect (see Table 10) for task development however their responses did produce a significant interaction (see Table 11) for gender by condition not found in the facilitator scores. Table 19 Source table for dependent variable -Working Alliance Inventory (t) task Sources of Variance Type ID Sum df Mean F Sig. of Squares Square Corrected Model 1796 808 17 105.695 1.342 182 ii 18ii I 18699.182 237.440 000 Ethnicity 14 136 2 Academic Learning Style 3. 797 1 Introversion/ Extraversion 26 073 1 Temperament Learning Style 209.490 3 Condition by Gender 63. 889 1 Condition by Ethnicity 230 013 2 Condition by Academic Learning Style 134 671 1 Condition by Introversion/ Extraversion 27 713 1 Condition by Temperament Learning Style 281.066 3 Error 8111. 606 103 Total 106234 000 121 Corrected Total 9908.413 120 a R Squared= 181 (Adjusted R Squared= 046) Table 20 : Means and Standard Deviation for gender variable Dependent Variable: Working Alliance Inventory task (therapist) Gender Male Female Mean 23 97 29.55 lil;I 1~111 ~Ill 7 068 .090 914 3 797 048 827 26.073 .331 566 69.830 .887 .451 63 889 .811 370 115.006 1.460 .237 134 671 1.710 194 27 713 .352 .554 93 689 1.190.317 78.753 Std. Deviation 12.774 7.149 Facilitators also noted stronger task collaboration in the computer-mediated condition than in the face-to-face condition. It is intriguing that both facilitators and participants reported gender differential in this dependent variable although they did not identify it in the same manner. Gender clearly is a factor which influences process and outcome efficacy in computer-mediated sessions.

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101 Table 21 Means and Standard Deviation for condition variable Dependent Variable : Working Alliance Inventory task (therapist) Condition Face to face Computer mediated Working Alliance Inventory Goal (therapist) Mean 27.74 28.65 Std Deviation 9 049 9.172 Again, as in the task sub scale the facilitators reported significant main effects for the variables condition (F = 4.01 p = 048) and gender (F= 7.34, p = 008) in the goal sub scale (Table 22) Means and standard deviation for condition and for gender are reported in Table 23 Table 22 Tests of Between-Subjects Effects Dependent Variable : Working Alliance Inventory goal (therapist) Sources of Variance Corrected Model if Ethnicity Academic Learning Style Introversion/ Extraversion Temperament Learning Style Condition by Gender Condition by Ethnicity Condition by Academic Learning Style Condition by Introversion/ Extraversion Condition by Temperament Learning Style Error Total Corrected Total a R Squared= .188 (Adjusted R Squared= .054) Type Ill Sum of Squares 2412.598 7347.594 ilf *' 53.847 7.147 37.032 91 743 147.608 318 927 186.915 6.964 468.334 10422.757 57318 000 12835.355 df 17 1 I 1 2 1 1 3 1 2 1 1 3 103 121 120 Mean F Square 141.918 1 402 7347.594 72.611 RU l32 tltO l Z l.21 ~26 924 266 7.147 071 37.032 .366 30 581 .302 147 608 1.459 159.463 1.576 186.915 1.847 6.964 069 156.111 1.543 101.192 Female participants were perceived to have or at least to have communicated greater session goal definition (M=20 72 SD = 8.48) than did males participants (M=14 28 SD =13 86) Sig . 151 .000 l lil .767 791 547 824 .230 .212 .177 .794 208

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102 Table 23: Means and Standard Deviation for gender variable Dependent Variable : Working Alliance Inventory goal (therapist) Gender Male Female Mean 14 28 20.72 Std. Deviation 13.864 8.477 Facilitators thought that participants, regardless of individual difference, showed greater abilities to formulate and define goals in the computer-mediated condition (M = 19 75, SD =10 17) than in the face-to-face condition (M=l8 74, SD= 10.60). Goal definition is extremely important in evaluating efficacy because unless the goal is rather specific it is difficult to assess its achievement. Table 24 Means and Standard Deviation for independent variable condition, dependent Variable : Working Alliance Inventory goal (therapist) Condition Face to face Computer mediated Mean 18 74 19.57 Std Deviation 10.597 10.171 In summary, condition, gender, and academic learning style were the independent variables that showed statistically significant main effects in the scales evaluated. Gender by condition was the only significant interaction and occurred in both participant and facilitator measures From the participants' perspective, visual learners predicted greater likelihood of seeking computer-mediated mental health services if they a re needed in the future than did verbal learners. Paradoxically, verbal learners indicated that they had greater computer and Internet skills than did visual learners. Participants' responses indicated that males were better able to collaboratively develop tasks with their facilitators to use to achieve their personal growth goal in the computer-mediated

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103 condition than in the face-to-face condition. Females were able to develop tasks equally well in either condition. From the facilitators' point of view, female participants were better able to develop an overall working alliance, than males. Female were better able to collaborative develop goal oriented tasks, than males (perhaps because they were equally good at developing task in each condition) Females were better able to define their goal for the personal growth sessions There were significant findings for experimental condition. Males were better able to develop a bond with their facilitators in the computer-mediated condition. Task development was better achieved in the computer-mediated condition Goal definition was more precise in the computer-mediated condition. While the evidence is not definitive, it is certainly consistent enough to suggest that individual differences do contribute to counseling process and outcome efficacy and should be further investigated. Qualitative Analysis Comprehensive qualitative analysis of the data collected is outside the scope of this project. However, some material is presented to illustrate and confirm the constructs presented in Chapter 2 presence, trustworthiness, and intimacy. Some participants expressed positive reactions to their experiences in the computer-mediated condition Comments from participants are replicated without change except when it was necessary to replace the facilitator's name withfacilitator in two comments. Grammar and spelling are explicitly overlooked for the sake of spontaneous communication during a session therefore those "errors" remain in the survey comments. The surveys were all completed on the Internet, and participants reasonably responded with the same disregard for writing mechanics as those in the computer sessions has been instructed to do.

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104 Presence -"It was cool to be able to just log online to talk, it was easily accessible, but instant messages sometimes lack tone of voice that can make it more difficult to understand the subtleties or conversation. plus, in some ways the annonymity of doing it over the computer was nice, i could cry or whatever without feeling watched and i could talk from the privacy of my own home that was both good and bad, good cause it was a comfortable place, bad because afterwards i couldn't leave some ... Trustworthiness -"I just really realized how helpful it is to talk to someone who is totally objective and knows nothing, or has made no judgments, about you. It was really cool to have facilitator because he went through some of the problems that I am going through right now, and he was able to disclose his experience with me and make me feel better about my decisions" Intimacy -I feel that using the computer was nice, it gave you a way to communicate, without feeling self conscious about what was being said" Other students were less happy with their computer-mediated experience. Presence "I think this is great to look at. However, I feel that the computer is an inefficient way to communicate thoughts to another person due to the ambiguous nature of the internet" "Having the counseling sessions over the computer made it seem as if we were wasting some of our time. There was sometimes a lag in the chat room, and I would often sit waiting to see what the facilitator had to say. I feel that the sessions might have been more productive in person. Further, I did not feel very comfortable having to type my feelings on the computer. It was a bit strange having to type "I am smiling" "I am laughing", ect" "I did not like the internet sessions that much because I tended to forget to sign on line. Ifl had an appointment to go to I feel that I would remember better Also, you could not see facial expressions or how the other person was feeling at the time. This is hard when you are" "There were times that I didn't know how to put what I felt into words. I feel that if I had been in an actual office with a therapist they may have been able to lead me through my feelings and putting them into words I think that when it comes down to it a person needs the one on one that an in office session gives." Trustworthiness The computer is not always reliable and to think that therapy will be given through the internet is depressing"

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105 Intimacy not getting the comfort of being in the same room as someone who is listening and caring Ambivalent responses included : Facilitator was very good and I felt very comfortable with her I think I would have preferred to be in-person though. " When online with your therapist you never know what they are doing, thinking or saying at that moment. Being online takes away the personal aspect of it. However I do think that the computer sessions would be a good back up like if the person had to go out of town on business or something" Some participants offered observations about the mechanics of Internet counseling that can get in the way of counseling Most people think faster than they can type so it can be frustrating in the chat rooms at times You have a lot to say but it takes a long time to get it ou t. Much different than talking on the phone or in person " Having to type stories that are really long" I had some distractions in my room when we were talking " it felt like a lot of time was wasted waiting for messages to go back and forth cause i was using my home dial-up computer that is sometimes alot slower than a T3 or dsl connection"

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CHAPTERS SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS The purpose of this study was to explore the efficacy of Internet counseling and the impact of individual differences on that efficacy. This chapter summarizes the study discusses the results and offers conclusions, and recommendations for further study. Summary of the Study This study was conducted in Florida with undergraduate student participants and graduate student facilitators from a university and a community college in the same municipality. One hundred and twenty one students volunteered to participant in three personal growth sessions and completed the sessions and five surveys ( demographics, learning style, personality traits working alliance, and outcome satisfaction) They were randomly assigned to either the face-to-face or the computer-mediated condition The ten counseling graduate student facilitators were trained and provided with a detailed procedure manual and report forms Each facilitator worked with an equal number of students in each condition Analyses of Variance were conducted using individual differences gender ethnicity learning style, and personality traits as the independent variables Follow up tests were conducted to analyze variables that demonstrated a significant main effect or interactions Conclusions Six hypotheses were examined and the results will be discussed individually Hypothesis I. The null hypothesis that there is no difference between face-to-face and 106

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107 computer-mediated counseling when process factors are compared was partially disproved with regard to gender task and bond Hypothesis Il The null hypothesis that there is no difference between face-to-face and computer-mediated counseling when outcome satisfaction is compared was disproved for gender as viewed by the facilitator Hypothesis m The hypothesis that a gender differential affects efficacy in counseling in general and between face-to-face and computer-mediated counseling was supported on several measures From the facilitators' perspective gender affected outcome satisfaction, with men reporting greater outcome satisfaction regardless of condition and greater task congruity with their facilitators in the face-to-face condition This is contrary to expectation because the previous research literature suggested that men are less willing to seeking counseling Therefore, it was hypothesized that males would be more comfortable with and more successful in the computer-mediated condition Results of this study suggest that although men are less likely to seek counseling as previously reported, when they do seek counseling they prefer it to be face-to-face The study indicated that males were less willing to engage in even mild counseling or personal growth sessions than females even when extra credit in their class was offered Eighty eight males initially expressed interest by completing the contact sheet and informed consent during the classroom recruitment however only twenty nine or 33 percent actually participated and completed the project in contrast to 42 percent of females. Peer pressure may have led students to sign up for the project in the presence of their instructor and classmates but to decline when individually contacted. Regardless of influences on participation and completion, males consistently produced results

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108 indicating that gender is a significant individual difference in predicting face-to-face or computer-mediated success. Hypothesis IV. The hypothesis that there is no interaction between ethnicity and efficacy in either condition could not be disproved in this study design although the relatively literature on multi cultural counseling suggests that race and ethnicity are important enough issues to warrant further research with a different design or different process and outcome measures Hypothesis V: The hypothesis that learning style differentially affects efficacy in counseling in general and between face-to-face and computer-mediated counseling was supported for prediction of future use of computer-mediated mental health services. Hypothesis VI: The hypothesis that there is no interaction between personality attitude (introversion/extraversion) and efficacy in either condition could not be disproved in this study design although the qualitative evidence in the relevant literature suggests that this variable is important enough to warrant further research with a different design or different process and outcome measures Limitations. The major limitations of the study were the age and subculture homogeneity of the participant population, and the acuity of the dependent variables The participants were young adults living in a rich, mobile cultural environment of college campuses The counseling and guidance resources were multiple and readily available (Counseling Center, Infirmary, Student Services, Resident Advisors, Activities Advisors, Coaches, Professors, and such) whereas Internet counseling is seen as most applicable to those with limited resources and access to mental health care. While this study did provide some significant results with the population involved, additional research is needed with

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109 clinical populations and geographically or situationally remote populations who have greater dependence on telecommunication for health care In retrospect a survey measure should have been developed to appraise the participants current Internet usage Areas to be assessed would include type of Internet provider service (IPS) number and names of listserv membership number and name of use group memberships frequency of chat room use frequency of bulletin board use number and nature of (personal vendors business) email use knowledge about and use of search engines It is an adage of social psychology that the best predictor of future behavior is current behavior therefore it would be instructive to see how the participants are currently using the Internet rather than or in addition to asking them to predict future use of Internet counseling as was done is the outcome satisfaction questionnaire It i s assumed that the computer and Internet competence of this sample population is probably greater than that of the general American population and population of potential clients Brief therapy and SO-minute therapy sessions have been demonstrated to be effective in face-to-face counseling However these time frames may or may not be equally effective in Internet counseling because speaking is generally accomplished faster than typing. If a person has difficulty producing speech, it is probably part of the problem for that he or she is seeking help The same is not true if a person has difficulty typing quickly concisely and/or correctly Dial up ISPs have an annoying habit of disconnecting that steals precious time from a session In this study the time frame was held constant for the two conditions This may have compromised the effectiveness of the Internet condition

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110 Implications and Recommendations Research The obvious implication of this study is that computer-mediated counseling is a viable mode for providing mental health services and in some dimensions surpasses face-to-face counseling in effectiveness Furthermore there is s preliminary evidence that there are significant individual differences that need to be explored to determine who is most likely to benefit from computer-mediated counseling and who should be referred to face-to-face counseling The suitability of a potential client and the appropriateness of computer-mediated With research-based information, including results in this study screening procedures can be developed that consider not just the presented problem but also the characteristics of the client who is seeking computer-mediated mental health services When potential clients have a choice of service modalities one size does not fit all. Isolated clients however may not have a choice of services For these clients the therapist's awareness of individual differences can be used to maximize the effectiveness of computer-mediated counseling even when in the best of all possible situations face-to face counseling may have been ideal. This study addressed only individual counseling Research must be designed and conducted to evaluate the potential for Internet group therapy that actually appears to be the most prevalent format in current usage The issues presented in the personal growth sessions conducted for this study were valid and legitimate concerns and most students felt that they genuinely benefited from the experience even when their original motive was extra credit rapport with the classroom instructor or altruistic desire to help and be a part of research. The nature of

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111 these issues did lead to referral to formal University or College counseling resources. Nonetheless persons motivated to locate and pay for Internet counseling will presumably be experiencing more serious problems, have fewer personal coping resources and/or a greater perceived need for services. The results of this study may or may not generalize to the population most likely to use Internet services Further study must incorporate this population A study of a clinical population could use any of a number of more objective, statistically validated outcome measures discussed in chapter 2 of this paper Clinical College students were willing to discuss serious personal growth issues over the Internet with a facilitator they had never met. They had certain assurances, to be sure, including but not limited to a copy of the Institutional Review Board contact phone number and email address. They met with the principal researcher in person when she recruited in their classroom They had access to the department and the dissertation committee chairperson through their classroom instructor They were advised of the specific campus resources available to them as students should their issues require crises, counseling, psychological or psychiatric intervention People without these immediate and serious recourses also seem to be willing to disclose private intimate information over the Internet. Given the number of counseling web site that exist clinicians must provide protection for vulnerable clients and must also consider ways to protect their own professional integrity Students did not ask if the project was safe and approved by the University, they were given specific documentation that described their responsibilities, protection, resources and recourses The Web counselor should be expected to provide the same information to potential clients

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112 This research indicates that gender and academic learning style affects the efficacy of counseling Web clinicians should consider incorporating this information into suitable screening procedure. There are certainly more critical issues to be included in screening such as emergency access phone numbers, medication (as an indicator of seriousness and doctor' shopping) however it should be disclosed to males seeking Internet counseling that "research suggests that" they might have better results with faceto-face counseling if that is an option for them Males should certainly not be excluded from computer-mediated counseling on the bases of this research Academic learning style is likely to be a factor that pre-selects those who seeking Internet counseling since it was found to be significant in measures of predicted future use and computer comfort and skill Because computer-mediated counseling is often suggested as particularly applicable for persons with disabilities, follow up research should be designed to compare keyboarded computer-mediated counseling and voice activated computer mediated counseling Even persons with disabilities who are not currently using voice activate computer access might be encouraged to do so if research bears out its benefit. Personal voice activate software has become cheaper than one traditional therapy session and might be provided by a third party payer in a medical needs' situation The code of ethics of Certified Rehabilitation Counseling (2002) is being revised and extended to include Electronic Communication and Emerging Applications ," section I addressing communication and the counseling relationship The results of this research indicated that section 12-B h Inappropriate Use should be expanded to include some recognition that individual differences may be include in this category as well as

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113 presenting problems' already include in this article of the code The NBCC (2001) ethics for the practice of Internet counseling includes a section entitled Internet Counseling Relationship which offered direction for dealing with suspected 'imposter' clients and minors The board should consider adding a item in this section about individual differences known and yet to be identified. Internet counseling exists As the professional associations struggle with developing working papers and preliminary ethical guidelines, the research community can provide the data needed to advise these decisions Clinicians must practice well and ethically to set the tone and expectations for this new frontier in mental health service. This study begins to explore the personal characteristics that can be used in potential screening for appropriateness of Internet services for a given client or population of clients or in the absence of clear cut reasons to pre screen, can be used to advise the therapist to insure that the differential potentials are considered The core issues remain to be investigated more thoroughly efficacy of Internet counseling format and restrictions to maximize efficacy, and individual differences of potential uses that can enhance or limit outcome results and satisfaction.

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APPENDIX A FORMS AND INSTRUMENTS Research Participant Information Sheet This information is strictly confidential and will be used only for purposes of this study including contacting the participant to schedule sessions, allow reporting to instructors for purposes of class credit where it is offered, demographics of study, and such Date: Name: E-mail Address: Local Phone number : Age : Gender: Race(s): Level ____ freshman ____ sophomore ____ Jumor ___ semor Major : Instructor : Class: Best day of week to schedule study sessions: __ M __ TU __ W __ TH ___ F Best time of day ___ mormng afternoon --___ evemng Disability accommodations needed (specify) Contact Information Sheet with demographic information Informed Consent Project Title: Process and Outcome efficacy of 21 st Century Counseling Techniques Please read this consent document carefully before you decide to participate in this study Purpose of the research study: 114

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115 The purpose of this doctoral dissertation study is to compare how students feel about his or her experience of personal growth sessions dealing with common issues faced by young adults. What you will be asked to do in the study: You will be asked to talk about issues that concern you such as adjustment to college life, relationship with room mate, adjustment to study demands, time management, stress management and such. You will be asked to participate in three one hour sessions with a research assistant. You will be randomly assigned to participate in these three personal growth sessions in person or via computer That is, you will either be assigned to three computer sessions or three face-to-face sessions You will be working with one person, a graduate student in counseling for all three sessions. The graduate counseling student will not be the primary investigator After the 3 rd session you will be asked to complete five ( 5) pencil and paper surveys so the last session will require one hour for your personal discussion and one hour to complete the surveys Time required: 4 hours Risks and benefits: You will receive three hours of individual personal growth guidance in working with a personal growth issue of concern to you. You may become distressed and decide that you need counseling that is available to you at the University Counseling Center. Compensation: You may receive extra credit in the course from that you were recruited if the professor offers it If this credit is available, it will be no more than 2% of the course point value. The investigator has no control over the awarding of points. If the professor offers points, you will receive them whether you complete the study or not. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your information will be assigned a code number. The list connecting your name to this number will be kept in a locked file in my faculty supervisor's office When this study is completed and the data have been analyzed, the list will be destroyed Your name will not be used in any report. Your professor will be provided with a list of students who volunteered if you are to receive credit but he/she will not receive any information about your participation nor whether you completed the study If you are assigned to the computer-mediated condition, you will be working on a secure (log-on, password, and firewall encryptions) web site, however there is a small chance that it could be

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116 compromised. The study results will be published as a dissertation and available in the University of Florida George A Smathers Library after it has been completed Voluntary participation: Your participation in this study is completely voluntary There is no penalty for not participating There is no penalty for deciding to withdraw from the study at any time Right to withdraw from the study: You have the right to withdraw from the study at any time without consequence Whom to contact if you have questions about the study Martha L. Grob le graduate student, Department of Counselor Education Martye@att.net (904) 387-2617 James Archer Jr PhD College of Education, Department of Counselor Education Jarcher@coe ufl.edu (352) 392-0732 extension 231 Whom to contact about your rights as a research participant in this study: UFIRB Office Box 112250, University of Florida, Gainesville FL 32611-2250 (352) 392-0433 Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description Participant: ______________ Date : ---Principal Investigator : _____________ Date: ---

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117 Outcome Satisfaction Questionnaire (participant form) NB : This instrument was administered online in the WebCT survey function using an Software application, Respondus so the participant view varied from this. They marked their responses by clicking in the appropriate radio button or text box, not depicted below. Question 1 The skills abilities, and experiences that I learned directly enabled me to reach the personal growth goal I set for these sessions extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 2 Being able to apply the skills, abilities, and experiences I gained in these sessions to resolve other stresses and concerns in my life. extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 3 The amount of information my facilitator gave me about my particular stress, concern, or problem extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 4 The amount of information my facilitator gave me about my mental wellness practice. extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 5 The relief from the stress or concern that these sessions provided extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 6 Overall rating of my facilitator extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 7 Overall rating of my personal growth session extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 8 How would you rate your computer skills ( e g ., keyboarding, word processing) and comfort? Computer guru good user skills adequate user skills novice skills computer phobic

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118 Question 9 How would you rate your Internet skills? Internet guru good user skills adequate user skills novice skills Internet phobic Question 10 Please tell us what you liked least about this experience. Question 11 Do you have observations, reflections or comments, that have not been addressed in these surveys, that you wish to share about being part of this study? Question 12 How likely are you to choose computer mediated counseling should you choose counseling at some time in the future? Very likely likely not likely would not not sure Outcome Satisfaction Questionnaire (facilitator form) NB : This instrument was administered online in the WebCT survey function using an application, Respondus, so the facilitator view varied from this. They marked their responses by clicking in the appropriate radio button or text box, not depicted below The participant link was labeled Outcome Satisfaction Questionnaire but the facilitator link was labeled Facilitator Survey 1 because all surveys were listed on the same screen It was a concern that the participants might try to second guess their facilitators rather than offer their own frank opinions, if they knew they were completing similar surveys The same convention was used with the Working Alliance Inventory label for participants and Facilitator Survey 2 label for facilitators. Question 1 participant ID and facilitator initials Question 2 The skills, abilities, and experiences that this participant learned directly enabled him or her to reach the personal growth goal set for these sessions extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 3 Participant being able to apply the skills, abilities and experiences gained in these sessions to resolve other stresses and concerns in life

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119 extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 4 The amount of information I gave this participant about his/her particular stress, concern or problem. extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 5 The amount of information I gave this participant about mental wellness practice extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 6 The relief from the stress or concern that these sessions provided this participant extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 7 Overall rating estimate of this participant's reaction to me. extremely satisfied very satisfied satisfied not very satisfied not at all satisfied Question 8 Overall rating estimate this participant's growth sessions extremely satisfied very satisfied satisfied not very satisfied not at all satisfied

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1 Logistics APPENDIXB FACILITATOR TRAINING MANUAL Table of Contents 2 Procedure section of dissertation proposal with protocol for each session 3 Record forms 4 WebCT access information with copy of each screen from http to chat room 5 Brief Cognitive Behavior therapy material from Meichenbaum 6 Computer Counseling Technique (articles listed in required reading) 7 College Student Personal Growth Issues (articles listed in required reading) Front pocket Treatment plan forms Progress notes forms Back pocket Facilitator checklist Contacts : Martye Groble Martye@att.net (904) 387-2617 Loren Groble Groble Robert@hotmail.com (352) 335-0118 (your local all-purpose helper) James Archer Jr. Jarcher@coe ufl edu ( dissertation committee chairman) 120

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121 Logistics Recruiting Participants: Researcher contacts instructors of undergraduate classes and get permission to recruit in their classes Researcher recruits in classes giving brief description and having volunteers fill out a contact sheet and a signed consent. The volunteer is also given a copy of the informed consent Scheduling Participants: Researcher or trained assistant will randomly assign the participant to one condition or the other. XXX will assign the code (to keep things simple since he has already begun facilitating) The code takes the form of two or three letters (the initials of the classroom instructor), four digits (unique ID), and two letters (facilitator's initials). Therefore, LMCxxxxDP is a student in Laura's class with Dan for a facilitator Use the code not the participants' name on all papeiwork and tapes. Once you have the contact sheet, contact your participant and arrange a mutually agreed upon time to meet. Be prompt or early Record all contact and results on your tracking sheet ( especially answering machine messages and no shows). FACE to FACE CONDITION The facilitator will contact the counselor education office to schedule a room for the face-to-face session. The facilitator will meet the participant outside the lab area, introduce him or herself and lead the participant to the assigned room (rooms will change with each appointment due to availability). Be sure you have gotten the key from the office, unlocked the room and checked for furniture placement and cleanliness before the participant arrives. These sessions are to be taped to keep the conditions equal and to evaluate adherence to protocol. Tapes will be provided Let me

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122 know what size you need for your recorder If you do not have a recorder, one will be provided for the duration of the experiment. Session should last 50-60 minutes If the session is shorter or longer than the norm, please make a note why It is fine; I just need to know why. Tapes, clocks, tissue) manila envelopes and any new handouts will be in the team mailbox so please check it regularly. If you leave materials be sure they are in sealed envelopes for privacy, COMPUTER-MEDIATED CONDITION Entering your participant into the WebCT system is a two part process Each participant has the last name Participant, and the first name alphanumeric code because these show up in the chat room Do not use the participant's name. Use the code for the password to keep things simple and private Use the code plus the numeral l to create a second account where you can complete the facilitator surveys for this participant (Your regular access level is TA and as such you can see but not do the surveys). WebCT automatically stores all dialogues so this privacy is paramount. If your participant already has a Global ID from another class he or she must not use it for this study because it would be recorded. The chat room format in WebCT is designed for class access not individual access therefore a participant might enter your session Please be very assertive in asking them to leave and return at their scheduled time Checking the chime entry box will help you notice if someone does accidentally enter. I do not anticipate this being a problem but be aware it could occur and be prepared to handle it. If two facilitators have scheduled a chat room for the same time, one should move to any empty chat room 1-4 Please do not use 5 or 6 with participants except as noted below.

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123 I will work with each facilitator to insure that you are comfortable using WebCT, working to the session room and helping your participants get there as well (Martye@att net). You can always get help from the university help desk 392-help for login problems Be sure you have these worked out for yourself and for your participant before your first scheduled personal growth session For big problems, Doug Johnson is a very user-friendly administrator ofWebCT and you can reach him through the CIRCA help desk Be sure to mention that project you are with when you leave him a voice message We are only using rooms 1 through 4 for participants, however I would like to schedule facilitator meetings with me in the general chat for dissertation room and you may use the General Chat for all rooms to consult with one another (but not with participants) The assessment tech will wait in room 5 during CMC administrations to answer any question or help the participant. STUDY MEASURES The facilitator fills out two measures at the end of the third session The participant will fill out four measures at the end of that session. Administration will be conducted by Loren so please give him your schedule of the last sessions so he can be present at the proper time to conduct the assessments. TAPES AND RECORDS When you have completed the entire process with a participant return tapes, treatment plans, contact sheets progress notes, and so forth to me. Tum in tracking sheets by email weekly so we can keep track.

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124 Session Structure Guidelines Condition 1 Face-to-face Session 1 Face-to-Face: 60 minutes Goals : To engage the participant in collaborative, cognitive personal growth counseling Objectives : To develop rapport with the participant To clarify the therapy process to be used To identify and clarify the participants issue-based goal To collaboratively develop a set of tasks to accomplish the goal Session 1 : The facilitator will welcome the participant and answer any questions. The purpose of the first meeting is to begin to establish a bond between the facilitator and the participant, explain the nature, language and methods of the CBT sessions identify the goals and tasks to be accomplished and make the next appointment. For face-to-face sessions this means discussing therapy conventions of freeze frame, stop action, focus on here and now, and other as listed in the training manual. For the computer-mediated sessions, the focus on here and now, cognitive reframing and homework are similar to the face-to-face session, however the subtle therapeutic interventions will differ in that rather than non verbal vocalizations, facial expression, body language and visual/spatial environment the action literally in the face-to-face session, the research assistant will teach and use bracketed emotions descriptive immediacy, and textual visualization The participant will need to practice these with the research assistant prior to the experiment until he is comfortable and confident using them. Session 2 Face-to-Face : 60 minutes Goals : To continue to build rapport and to process work to date Objectives : To continue to develop rapport with the participant To review independent participant work to date To process experiences relevant to tasks and goals since last session

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125 To collaboratively revise, enhance, or focus the set of tasks to accomplish the goal Session 2 : The facilitator will welcome the participant, ask about the homework and tasks completed during the past two weeks since the first session, review work accomplished and work not accomplished. Review the goal and tasks to accomplish that goal Discuss progress and obstacles to success. Plan tasks for next two weeks Session 3a Face-to-face Goals : To review work of three sessions and bring about satisfactory closure Objectives : To continue to develop rapport with the participant To review independent participant work to date To process experiences relevant to task and goal since last session To highlight gains made during therapy To plan ongoing self help tasks To bring about satisfactory closure and make referral is necessary. Session 3a : The facilitator will welcome the participant and work through closure and termination activities with participant, review progress, homework accomplished and not, and plan for the participant's further self help Session 3b Face-to-face Goals: To evaluate the working alliance, outcome satisfaction and individual differences of the participants Objectives : To continue to develop rapport with the participant To administer the evaluation instruments To thank the students for their participation Session 3b : The facilitator escorts the participant to the computer lab, helps them log on, make sure the tech is in the help chat room, and give the student the laminated cards to help with the session The facilitator will complete the WAI T, his or her assessment of the therapeutic relationship Computer-mediated Sessions are similar with the following exceptions

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126 Session I Computer-mediated Goals: To engage the participant in collaborative cognitive personal growth session Objectives : To develop rapport with the participant To clarify the therapy process to be used To teach text-talk non verbal techniques To identify and clarify the participants issue-based goal To collaboratively develop a set of tasks to accomplish the goal Session 3b Computer-mediated To continue to develop rapport with the participant To guide the participant to the survey section ofWebCT and verify that the tech is in the help chat room To thank the students for their participation

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Plan Participant ID: Presenting Issues(s) : Participant Strengths : Resources: Goal(s) : Ways to reach goal : Session 2 and 3 Participant ID 127 Therapy Plan and Progress Notes Counselor ID: Date: Condition: Facilitator ID Condition Progress Notes (date each entry)

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Participant ID 128 Facilitator Checklist Facilitator initials Instructor 1. 2. 3 ___ get contact sheet that has been coded and assigned to a condition ___ contact participant and set up first appointment --contact department secretary to reserve a room for F2F sessions OR ___ contact the participant and instruct on the WebCT log-on procedure prior to the first CMC session 4. ___ check tape and recorder for F2F condition, call helper if you need either at 355-0118 5 ___ conduct session 6. ___ schedule next session 7. ___ repeat 2 through 6 above 8 ___ contact and schedule assessment tech to be present in person or on-line during assessments 9. ___ conduct final session 10. ___ introduce participant to assessment process and tech 11. ___ complete the WAI (t) and the OSQ (f) for this set of sessions 12 ___ put all three tapes treatment plans and progress notes in manila envelope, label with the participant's code in the top left corner and put in team box or contact helper for pick up

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129 Sample of tracking sheet Tracking record of all volunteers regardless of degree of completion This record is meant to account for each volunteer Fill in the code ID for each volunteer whether they actually participate or not. Indicate F2F or CMC under condition Put a check mark under each session completed Use the note column to mention anything usually (eg The woman who never intended to participate) We need each record so we can determine drop out rate and such # # P rfc tNbr Notes, Participant Facilitator~~~ta ~~:: sessions surv~;sipan =~~!~~or comments complete complete complete LMC0001 Dan x LMC0002 Dan x X LMC0003 Dan x LMC0004 Dan x X LMC0005 Dan x X LMC0006 Dan x LMC0007 Dan x X LMC0008 Dan x X LMC0009 Dan x LMC0010 Dan x X LMC0011 Dan x X LMC0012 Dan x LMC0013 Dan x X LMC0014 Dan x X LMC0015 Dan x X LMC0016 Dan x X LMC0017 Dan x X LMC0018 Dan x X LMC0019 Dan x X LMC0020 Dan x LMC0021 Dan x X LMC0022 Dan x LMC0023 Dan x LMC0024 Dan x LMC0025 Dan x X Sample Screen Shot training pages 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 finished 2 finished 2 finished 2 finished 2 finished 2 finished 2 finished scheduled 2 finished 2 finished 2 finished 2 finished 2 finished 2 finished 2 finished dropped 2 finished

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130 WebCT Samples Screens Checking your participants survey status With TA level WEBCT access you can check the status of your participants and know who has completed their surveys and who has not You must do this one survey at a time. To get to this screen click on the opinions icon on the first page of the study site You will see something like screen shot I below. You cannot bring up the surveys here because as you can see they are not hot links ". However you can see two hot links blue or purple with underlines The date and availability are also blue but I think that is just to make them easy to find The live links are the ones with underlines By clicking on a submissions link you will see a screen like the one captured in screen shot 2 below The detail link is illustrated in screen shot 3 On the right you have some options ( second set ) to help you find what you want without flipping through all the next and previous buttons Screen Shot I First page of survey section 1:M,s i, 1 rt..U-~ '~,e,o Qu i:t .... d SUl'YYMllnaorn.nt ;,:;: :.~: :.~::: :: :~::~ ~ ~ ~=: ::;;; ::=::~:: : 5 ::~~:~::::: :: < :~ ::.:c: : ~-~~~., -:::~'~Mt._., 1-rne 1"'>~~ ~ ~,--=. <7~ 1!!! 111'\d L~ Mott-.., .. IE ~,....u .ACl, MS .... M rA" ~V'C-1'.:',i ~Y W~::r h .:. w~v,._ .;y, .. u ..u M c--'.-u,pjt:flt l>i.au,c, ~r -cad\. ,:r'~$Q.',o al -tar.-h ,ur,,."f"/, '1"' .. ".,. al'ISWau l!A" A\}"l'(V,IUt', .t"bcsnuie o,., ~ .-.. c WT"'-" ~n A~ !Qf'tb.ot ns~cla k' MR iA it\ -r,h,_ \.~nt-Yot d\0:r.r .. -.m t lv ~.,.s-M':~ -". f\ 2"1!'1.'!:o.rr. h. ~,..-:y Q:.<-.wr. v ,.t it. tl\i;ir ,s.~ c-l'l t> .". t w. ,,.,. (\tf)f,.r #htt:Ot c-t.M' :,-_.. ,..~) !r y,)a h.. vr. 0:-17 ,j(v.~> r, f',~.o,, /. ~~ .. dle-n c.Jx,k < 0. : l\11' l>~~ <.'""'"Ch :";;'tt~>J(.!0. :< >: I ,,,"to:~ f '-""< l'!('J~~ ::. 5') '" d~ ,: \wt <<--Wtl ~ : ttOOo '!'b:iaok y->:tt.:x : yoo,x ::::::::~~ : ::2 lOCO l .. ........._ ~ ~ l" ...,_ .. -,.,,..,._;ai :, : :: :1:_' _,_:i, i.: 1 --~~:! ~ ~ .1 ~~~!"!11 ,........ ..u. r"raTJ ,.._, J'clo'WyOt :n.tl~!>U SU:ll~ ew9KS tS c:2J!biC Tw : t.:,~.> ;f ,,.._, 'F-tMiot7~ ::l>~:.t2:::> 'Iv : t.:,~J. ,..._, Fo&M:_,.m .,. :a :z rem ,.., liJllm.1~~ ...,_. P T w : U~:ii&oN~~ f8w:::1MkiMtO::::t\ ~~=f :-: :=:: :~~::..::;~ = &.. :U~>0.30
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131 Screen Shot 2 Submission option from previous screen shot. Note the blue highlighted next page button -that means there are more pages with lists. Once you go past page 1 the previous page box will also be "live" blue lighted, blue =' '' ~i..u n \' : ' . ~,._ ~' ',:. ' ' Din~ft.ttlon Reseatcti Stud'/ J~;;~~ ) ~~i?.~ : ) s~ Submisaians: MBTI :=;:.0:-~ci: ., c ,, J Screen shot 3 Using the detail hot link you can see the participants actual responses I sincerely request that you not do this for the participant's privacy and confidentiality. There is no way I can block this option in WEB CT so I am trusting each of you to respect the participant's privacy.

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Detail : MSTI l,;iW<~fi-] ,:;, : ,:;; Dlne~~n ~!Sellf'Ch Study ~~Y '-N. V,t...e)O ~;; t !~ 132 "" Options ?: SHn:h Sud> j...a rt>C..'>)C:~ .. @ V'lllue i@ !MlM Manaa Columns .. a:1 nc-:4,i$ ,.. t:p!~ NttJ~ r ~r co!um'. r E,;:,.r.: ,ww;,t<> ... lWJ ~-:'!-: : ;~:-:: :-, s-: :"':vi .:J : ..... ~-M:aiaagr. :: :xo: :: := : : :> ~ :: '-,: ~ -: :: : : _. :.:::-;:;f: } :. ; :;; : : ; ~~::: ~ ::: :",: : : h"!-:;;:.1 _. .,.,. :,.. t/:;;.: : ~,;;f ~:-:-. : :"':t :: :r (;{( :; ]:l.:;;;tt ;,; ,;,;,~;;;:::=:,;;,;;;; 1 :::::::::::::::::::::::::::::::1:::::1:: ; :: ; : ; :: ; :: ;; 1::::; ;;;;;;;;;4:;1;,;~;;r.. 1: ~~;;; ;: Required Reading Study Protocol These articles must be read prior to beginning tow ork on this project so that we are all working from a common body of information. You may borrow the researcher's copies All articles are available in the Educaiton Library, Library West, the Health Science Library on the Internet, or are included (*) in your manual. You are also welcome to read the entire dissertation proposal but that is certainly not required or necessary You may download the WebCT manual from http://www.webct.ufl.edu but this is not necessary and it contains a great deal of information you do not need. Colon, Y. (1994) Chatter(er)ing through the fingertips: Doing group therapy Internet [web document]. Women and Performance Retrieved 2/15, 2001 from the World Wide Web : http://www echonyc com/~somen/Issue 17 /public-colon.html

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133 *Meichenbaum, D (1988) Cognitive-behavior modification workshop Boston, MA : Harvard Medical School--Massachusetts General Hospital. Meichenbaum, D (2000). Treatment of individuals with anger-control problems and aggressive behaviors : A clinical handbook. Clearwater FL : Institute Press Murphy L. J. & Mitchell D L. (1998) When writing helps to heal: E-mail as therapy British Journal of Guidance & Counseling, 26 (1) 21-32 Rinaldi A.H (1998) The Net : User Guidelines and Netiquette Florida Atlantic University (web document). Retrieved 07/14 2001 from the World Wide Web : http://www fau edu/netiquette *Suler J. (1997) Text-talk : Psychological dynamics of online synchronous conversations in text-driven chat environments Rider University(web document) Retrieved 02/10 2001 from the World Wide Web: http : //www rider.edu/users/sule/pscyber/texttalk html. *Z Boray D (1997) The UnOfficial Smiley FAQ : author (web document) Retrieved 09/06 2001 from the World Wide Web : http : //www newbie net Required Reading College Student Counseling Archer Jr. J. & Cooper S. (1998) Counseling and mental health services on campus. San Francisco Jossey-Bass Publishers Cooper S & Archer Jr ., J. (1999) Brief therapy in college counseling and mental health Journal of American College Health, 48 (July) 21-28 Murphy M C & Archer Jr J. (1996) Stressors on the college campus : A comparison of 1985 and 1993 Journal of College Student Development, 37 (1) 20-28 Steenbarger, B N (1992) Intentionalizing brief college student psychotherapy ." Journal of College Student Psychotherapy, 7 (2) 476 Wilson, S. B. (1978). Cognitive intervention in the normal developmental problems of young adults Journal of College Student Personnel, 29 (March) 136-140

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APPENDIXC COMPUTER-MEDIATED SESSION TRANSCRIPT This is a transcript of a computer-mediated session recorded by the WebCT system and downloaded to the researcher's computer. Only the researcher had the level of access required to see and download these logs. The only editing removed the participant's identification code and the facilitator's name. All spelling and grammar remains as produced. Samples of the facilitator's use of Internet counseling techniques emotion bracketing and textual visualization, described in Chapter 2, are highlighted in gray. Also noted in gray is the facilitator's explanation of the limits of confidentiality and the facilitator's amplification of the participant's use of the emoticon "lol". Lol is one of the most common emoticons used on the Internet but it is an acronym with multiple meanings laughing out loud, lots of love, and lots of luck therefore it was important for the facilitator to find the precise meaning the participant intended A ********************************************************************** ***** New session has begun in EDU DISS Rooml. Time: Mon May 20 17:02:27 2002 *A*********** ********************************************************** ***** *+**** --FACILITATOR entered EDU DISS Rooml. Time: Mon May 20 17:02:27 2002 FACILITATOR>>This is Session one again for *+**** -PARTICIPANT entered EDU DISS Rooml. Time: Mon May 20 17:16:14 2002 PARTICIPANT>>sorry I got lost FACILITATOR>>Hello, I just wrote you an email! FACILITATOR>> 134

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135 FACILITATOR>>Was it hard to get in? PARTICIPANT>>yes . well I did not click on the dissertation link PARTICIPANT>>at first FACILITATOR>>oh, no, that can get real messy FACILITATOR>>Everything works fine until it doesn't m,~Mliw.l~) PARTICIPANT>>lol FACILITATOR>>How are you doing? PARTICIPANT>>fine PARTICIPANT>>and u? FACILITATOR>>good. I have had a crazy morning, I work part time in Shands psychiatry, and I showed up for 2:30 for the group, but it was at 1:00! FACILITATORSo I missed it all JW,ffii ij) PARTICIPANT>>Sorry to hear that .. I hate those kind of days FACILITATOR>>yeah FACILITATOR>>what about yours? Did you have class today? PARTICIPANT>>yes, I enjoy my classes they are pretty easy going right now FACILITATOR>>have you taken any Internet? PARTICIPANT>>never FACILITATOR>>so you are fresh! (j [tiit'.~tj@w.illinifi.ffiHii#l'l What we could do to you! PARTICIPANT>>lol FACILITATOR>>So, I want to explain a little bit about what this is going to be like. Is that cool? PARTICIPANT>>yes FACILITATOR>>! will spend about 5 10 minutes explaining a couple things, then we can talk about the "meat", and then in the end we will try to come up with a "plan" or homework for you to do until the next time I see you PARTICIPANT>>okay

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136 FACILITATOR>>The next two sessions will be pretty much the same, except hopefully I fi~WlH ~ I won't have to spend that time in the beginning explaining PARTICIPANT>>okay FACILITATOR>>About halfway through the third session, we will finish up and then I will guide you to the quizes that you take at the end, there are 4. FACILITATOR>>Any questions so far? PARTICIPANT>>nope :-) FACILITATOR>>Ok, then FACILITATOR>>but .. there are some exceptions to that confidentiality PARTICIPANT>>what are they FACILITATOR>>Other than that, what is said here, stays here. Make sense so far? PARTICIPANT>>yes FACILITATOR> >cool : U!fflffi\i) I FACILITATOR>>the only other thing I wanted to say a little about is FACILITATOR>>that counseling is a little different than other relationships inasmuch as it is all about you PARTICIPANT>>ok FACILITATOR>>you are free to ask me questions if you want, even if it is personal, but I will always hestitate to answer to make sure that the conversation doesn't change to focus on me, cuase that's not the point PARTICIPANT>>ok FACILITATOR>>and that also, you are really doing the counseling, all day everyday, and the sessions themselves are more like checkups or coaching sessions

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137 FACILITATOR>>ok, whew! After all that, any q's? PARTICIPANT>>ok PARTICIPANT>>no FACILITATOR>>then FACILITATOR>>tell me what we are here to tak about FACILITATOR> >talk :l q9.p~H) :m PARTICIPANT>>what area are you mostly concerned FACILITATOR>>what do you mean? What area am I mostly concerned with? let me turn the question around --what area are you mostly concerned with? PARTICIPANT>>personal relationship PARTICIPANT>>relationships FACILITATOR>>with a friend? boyfriend? tell me more PARTICIPANT>>boyfriend, I have this fear of commitment and I know where it came from but I just don't know how to get rid of it. I always question behind a guys motives for telling me his feelings even if we are dating (like movie and dinner) FACILITATOR>>are you dating someone now? PARTICIPANT>>several PARTICIPANT>>I am scared to limit myself to one person FACILITATOR>>l:t:W.I!! PARTICIPANT>>lol FACILITATOR>>oh, I see, so you think that's why you are dating several at a time PARTICIPANT>>yes FACILITATOR>>how many are we talking here? PARTICIPANT>>three PARTICIPANT>>they are nice guys\ FACILITATOR>>so, you are dating three guys because you are afraid to limit yourself to just one. Before we go farther, let me ask -do you like all of them?

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138 PARTICIPANT>>good question lol PARTICIPANT>>one is an ex, one likes me a heck of a lot more than I like him, and the other I could see myself with if I could get pass this "situation" FACILITATOR>>I see PARTICIPANT>>laughing out loud FACILITATOR>>ok, good FACILITATOR>>I wasn't sure FACILITATOR>>ok, so one is an ex, but now are you still kinda dating him? FACILITATOR>>or is it totally over? PARTICIPANT>>no PARTICIPANT>>he caused this fear FACILITATOR>~9.lj. So right now you are only dating two PARTICIPANT>>yeah ... I guess so FACILITATOR> >wait, wait, wait = ]#.R f l. t Mit i tlt 1l ffii% fil: !ilm!@.ii t fel!s l li~lm what do you mean I guess so? PARTICIPANT>>Well, the ex is .... I don't want him back. I keep him around for comfort PARTICIPANT>>do you get what I mean FACILITATOR>>I am getting the idea--but not total just quite yet .. FACILITATOR>>you still mess around with him? or .. you still call him on the phone or? l {infi.!f.~~ I P,ffiffl f) J.i.ggf II .j [ ;i II Bi!ffll PARTICIPANT>>straight to the point ..... we mess around when I say so ... comfort! You get me now? FACILITATOR>>got it FACILITATOR>>ok, and the other one, he likes you a lot more than you like him FACILITATOR>>and then the third ... ok, we got it. PARTICIPANT>>:-) FACILITATOR>>so, you said that your ex made you this way, and that you think you know why. tell me what happened

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139 PARTICIPANT>>well .... PARTICIPANT>>we were together for a year and a half PARTICIPANT>>and I told him eight months into the relationship that I loved him FACILITATOR>>and you meant it, or you just told him? PARTICIPANT>>I meant it .. he waited longer to say the same becuz he said that he did not take that word lightly PARTICIPANT>>i meant it FACILITATOR>>and, I am guessing something happened, right? PARTICIPANT>>yes PARTICIPANT>>we started going through problems. he was taker and I was always the giver. FACILITATOR>>did he ever return the words? PARTICIPANT>>I felt like he did not appreciate me.yes, he said he loved me FACILITATOR>>and when it broke off, who broke it off, you? I am guessing, if you still keep him around? PARTICIPANT>>After about three months of going through arguements off and on PARTICIPANT>>I did broke it off because he told me one night during a conversation that he did not love me nor did he know if he meant it the first time. We were just having a conversation FACILITATOR>>oh man PARTICIPANT>>break it off FACILITATOR>>it hurt really bad, right? PARTICIPANT>>something in me change from that night. I never cried so hard in my life. PARTICIPANT>>it still hurts FACILITATOR>>yeah PARTICIPANT>>I don't want that feeling ever again. FACILITATOR>>did you all break it off then, or did you kinda hang on for a while? PARTICIPANT>>I returned the favor FACILITATOR>>you mean you told him the same thing?

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140 PARTICIPANT>>revenge is sweetest when he feels what he dished out FACILITATOR>>or you acted in a way to make him feel bad FACILITATOR>>like cheating on him, etc. PARTICIPANT>>! told him that we would just separate for a "minute." I kept him around like we were still "together." FACILITATOR>>got it PARTICIPANT>>! told him that I was going to date other people FACILITATOR>>and that was how long ago? PARTICIPANT>>! did PARTICIPANT>>spring 2001 PARTICIPANT>>about feb late jan FACILITATOR>>did it feel better when you hurt him? or about the same? PARTICIPANT>>liberating PARTICIPANT>>i still cared for him but he needed to know that he could lose me FACILITATOR>>but now .. although it was liberating in the moment, you are not liberated now, in fact, trapped FACILITATOR>>right? PARTICIPANT>>well FACILITATOR>>cause you said you need to get over your "problem". Or did I misunderstand? PARTICIPANT>>liberating in the sense that I realized that I had the power to hurt him take the situation into my hands PARTICIPANT>>before I was the one crying PARTICIPANT>>you are correct FACILITATOR>>the question is now ---do you want to get back with him? would he? would you? or you think you need to just sort out and move through your feelings, but move on? FACILITATOR>>we probably won't be able to make your world "perfect", but if you had a magic wand -how would it be? PARTICIPANT>>no.yes.not right now. correct

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141 PARTICIPANT>>I would change his outer appearance and give him another chance. I have changed over the year and my prefences are very much different now. Appearance wise. FACILITATOR>>how would you see things right now but in your perfect world? FACILITATORok, ignore my last comment! J: iffl l i f FACILITATOR>>but, what about his inner, are you still in love with that? PARTICIPANT>>Fred would be taller, slimmer, no drama attached. I love him, but not in love. FACILITATOR>>got it FACILITATOR>>ok, so let me tell you ... we are going to try something called REBT. Basically, it is a way of analyzing you actions PARTICIPANT>>ok FACILITATOR>>I'm going to try to explain a little bit about it, and then give you as "homework" something to use it on PARTICIPANT>>ok FACILITATOR>>Basically, when we have an event and then a reaction~ we often have a thought in the middle of it that influences our reaction. But, often, we aren't aware of the thoughts FACILITATOR>>so, we react "without thinking". FACILITATOR>>for example, I come home from school, the dishes are still in the sink, and my husband is there and has been home all day PARTICIPANT>>you yell FACILITATOR>>! get mad, because the dishes aren't clean FACILITATOR>>right FACILITATOR>>but the underlying thought there that made me angry was that he was lazy, and could have or should have cleaned up the dishes PARTICIPANT>>ok FACILITATOR>>now, that thought can or cannot be correct, but if I change my thought process, I might not get mad PARTICIPANT>>ok FACILITATOR>>for example, if instead I think, "well, he must have been doing something very stressful in order not to be able to clean up the dishes", then how might I react? PARTICIPANT>>calm

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142 FACILITATOR>>you got it. FACILITATOR>>so, what we can do is this. Maybe we might need to sort through your thoughts and feelings a little more next session, but you said that at least right now you just want to work through your feelings and get over them FACILITATOR>>right? PARTICIPANT>>yes FACILITATOR>>so, what I was explaining is with REBT what we try to do is figure out our underlying thoughts that might be getting in the way PARTICIPANT>>ok FACILITATOR>>so, how do you think we might apply that to your situation with Fred and/or the other guys? FACILITATOR>>got any ideas? PARTICIPANT>>fear of commitment has an underlying thought of "I will be deceived"? FACILITATOR>>good. But even more so, "I will be deceived every time?" really good PARTICIPANT>>i see PARTICIPANT>>:-) FACILITATOR>>so, since this is coming to a close, what do you think we could have you do for this week until next session? PARTICIPANT>>I don't know PARTICIPANT>>talk to the guy that I could see myself with? Confront old boyfriend? FACILITATOR>>Those could be ideas, but probably right now you need to confront yourself more than others. cause for example you said that you might like the guy if YOU could get over this. but that might come at a later stage PARTICIPANT>>ok FACILITATOR>>how about you make a list of three things that Fred did, and how you reacted. And then try to apply what we were talking about, about the underlying thoughts, and how you carry them over. FACILITATOR>> FACILITATOR>>Does that make any sense at all?

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143 PARTICIPANT>>yes FACILITATOR>>good. so, it is about that time that we should go, any questions before we end? I will see you next week at this time FACILITATORthat was a question :t: Jm;Ml @m FACILITATOR>>oops againl FACILITATOR> >. he t tie PARTICIPANT>>yes PARTICIPANT>>lol PARTICIPANT>>:-) PARTICIPANT>>I enjoyed myself FACILITATOR>>good, so did I! FACILITATOR>>See you next week! PARTICIPANT>>i never really talk about myself PARTICIPANT>>bye *-**** --FACILITATOR left EDU DISS Rooml. Time: Mon May 20 18:21:54 2002 *-**** --PARTICIPANT left EDU DISS Rooml. Time: Mon May 20 18:22:00 2002 ************************************************************************ ****** Session in EDU_DISS_Rooml ended (all PARTICIPANTs have left). Time: Mon May 20 18:22:00 2002 ************************************************************************ ******

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LIST OF REFERENCES Ainesworth, M (1995) Protecting privacy. [web document] Mentanoia.org Retrieved 07/18 2001 from the World Wide Web : http://www.mentanoia org/imhs/therapists5 .htm. Ainesworth, M (1996). Internet therapy consumer survey [web document] Mentanoia.org Retrieved 07/18 2001, from the World Wide Web : http : //www.mentanoia org/imhs/ cybertherapy/ survey0 1 htm http : //www mentanoia org/imhs/cybertherapy/survey02 htm http : //www mentanoia org/imhs/ cybertherapy/ survey03 htm Akins T. Hollandsworth, J. G & O'Connell S J. (1982) Visual and verbal modes of information processing and their relation to the effectiveness of cognitively based anxiety-reduction techniques Behavior Research and Therapy, 20, 261-268 Akins T ., Hollandsworth, J. G & Alcorn, J. D (1983) Visual and verbal modes of information processing and cognitively based coping strategies : An extension and replication Behavior Research and Therapy, 21, 76973 Alexander L. G & Luborsky L. (1986) The Penn Helping Alliance Scales In L. S Greenberg & W M Pinsof(Eds ) The Psychotherapeutic Process: A Research Handbook (325-366) New York, NY : Guilford Press. American Counseling Association (1999) Ethical standards for Internet on-line counseling. [web document] American Counseling Association Retrieved : 05/03 2001 from the World Wide Web : http : //www counseling org/gc/cybertx.htm. American Medical Informatics Association. (1998) Guidelines for the Clinical Use of Electronic Mail with Patients [web document]. AMIA Retrieved 06/03 2001 from the World Wide Web : http : //www amia org American Psychiatric Association. (2001) American Psychiatric Association (AP A) principles of medical ethics with annotation especially applicable to psychiatry [web document] APA. Retrieved 06/03, 200lfrom the World Wide Web : http://www. psych org/psych/htdocs/apa members/ethics_ index html. American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorder, (Fourth Edition) Washington D C .: American Psychiatric Association 144

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159 Wood C. (2001). Thinking it throughCounseling interventions [web document]. Connexions NSWHEALTH Retrieved 01/13 2001, from the World Wide Web : http :// www.ceida net au Wright, P & Greengrass, P (1987) Spycatcher : The candid autobiography of a senior intelligence officer. New York, NY: Viking Penguin. Yalom I. D (1995). The theory and practice of group psychotherapy New York, NY Basic Books Inc. Young, C (1996). A kinder, gentler glossary for net neophytes and others [web document]. Women and Performance Retrieved 05/12 2001, from the World Wide Web : http : //www echonyc com/ ~ women/Issuel7/glossary.htm. Z'Boray D. (1997). The UnOfficial Smiley FAQ : author (web document) Retrieved 09/06 2001 from the World Wide Web : http :// www.newbie net

PAGE 171

BIOGRAPIIlCAL SKETCH Martha Lana Bogardus Groble was born near Meadville, Pennsylvania on September 4, 1947 She graduated from Cochranton Area Junior Senior High School in May 1965 and attended Indiana University of Pennsylvania where in January 1969 she earned a bachelor's degree with honors in Education (majoring in mathematics) She taught 7 th and 8 th grade mathematics at Roosevelt Jr. High School, Altoona, Pennsylvania before enrolling in the University of Oklahoma where she earned a master's degree in Anthropology in 1971 She conducted or participated in academic fieldwork in southeast Alaska; the Yucatan peninsula; San Jose, California; and Sierra Leone, West Africa. She worked in education, collections, and exhibits at the Stovall Museum of Science and History; the Jacksonville Museum of Science and History; the Riley County, Kansas Historical Society; and the Kansas State University Planetarium During her time in Kansas, she taught physics and anthropology at Kansas State University After a parenting hiatus of several years, during that she was active in school, community and volunteer service she established and worked in a psychiatric practice in 1983 In 1986, she enrolled in the University ofNorth Florida and earned a master's degree in counseling psychology in 1989. She earned her license in mental health counseling in 1992 and continued to work in the psychiatric practice. In 1993, she was awarded a Veteran's Administration contract for vocational rehabilitation counseling To enhance her ability to provide excellent services to her veteran clients, she enrolled in the University of Florida, College of Education, Department of Counselor Education to earn 160

PAGE 172

161 a Ph.D. in mental health counseling (specializing in vocational rehabilitation counseling) in the fall of 2002 She is a certified rehabilitation counselor and a certified career assessment associate. She is an adjunct instructor at the University of North Florida in the department of Rehabilitation Counseling and she is the primary care giver for her husband's neptuagenarian parents who live with them. As a mathematics major, Dr Bogardus began learning computer programming in 1967 Her knowledge and skills grew as the computer world became accessible to individuals. She designed the computer lab at St. Mark's Episcopal Day School in 1993 and focused her graduate research in the area of computers and counseling She is an avid genealogist, proficient in the use of computer data bases to research lineages. She records her findings in traditional scholarly format and in personal photographic journals that she shares over the Internet in prominent genealogy sites, and on her family website She enjoys textiles including sewing and quilting with a computerized sewing machine, and hand stitching needlepoint, petit point, crewel, and embroidery She relaxes by reading fantasy literature (brain candy) and enjoys fantasy role playing gaming When away from her computers, books and 30-sided dice, she hikes, swims, canoes rafts, sails, and backpacks on four continents with plans to explore two more continents Although she and her family camp extensively and world wide as a family or with Scouts and friends, her favorite campsite has always been Holiday Inn poolside

PAGE 173

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy James Archer Jr., Chair Professor of Counselor Educati I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy. Professor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality as a dissertation for the degree of Doctor of Philosophy Professor of Rehabilitation Counseling I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy 2tt}~~M David Miller Professor of Educational Psychology

PAGE 174

This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy December 2002 Chairman, Counselor Education v--De Dean, Graduate School

PAGE 175

J LD 17 8 0 20_ 02 l i13 UNIVERS I TY OF FLORIDA \\ \ \\ \\\\\ \ \\\ \ \ \ \\ \ \\ \ \ \\\ \ \ \ \\ \ \\ \ \ \\ \\ \ \ \\\ \ \ \ \ \ \\ \ \ \\ \\ \ \\ \ \ 3 1262 08557 2476


90
Level of Computer/Intemet Skill
Academic learning style produced a significant main effect when participants
were asked to describe their level of comfort using computer and the Internet and their
computer and Internet skill level (F = 3.95, p = .049). Table 5 depicts all of the results of
the analysis for this dependent variable. The lower scores indicated greater comfort and
skill while the higher scores indicate less comfort. Participants who endorsed the visual
learning style preference estimated their computer skill to be more limited (M = 4.56, SD
= 1.53) than did participants who endorsed the verbalizer or auditory learning style
preference (M = 4.03, SD = 1.03), contrary to expectation. Verbalizers had better skills
and greater comfort but visualizers predicted greater future use.
Table 5. Source table for dependent variable computer/intemet skill level (participant)
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
28.445
17
1.673
1.297.209
Intercept
532.841
1
532.841412.975.000
Condition
.804
1
.804
.623.432
Gender
2.929
1
2.929
2.270.135
Ethnicity
4.740
2
2.370
1.837.164
Academic Learning Style
5100
§
5.100
3.953.049
Introversion/ Extraversin
5.866E-02
i
5.866E-02
.045.832
Temperament Learning Style
4.434
3
1.478
1.145.334
Condition by Gender
7.398E-02
1
7.398E-02
.057.811
Condition by Ethnicity
.876
2
.438
.340.713
Condition by Academic Learning Style
2.417
1
2.417
1.873.174
Condition by Introversion/ Extraversin
.282
1
.282
.218.641
Condition by Temperament Learning Style
4.021
3
1.340
1.039.379
Error
134.186
104
1.290
Total
2253.000
122
Corrected Total
162.631
121
a R Squared = .175 (Adjusted R Squared = .040)


29
Cheskin Research and Studio Archetype/Sapient (1999 because of it is vital component in
ecommerce. Web site and email security were discussed in length below because
cyberspace is mysterious to many users and because privacy, confidentiality and
credibility are essential factors for instilling a sense of trust.
Intimacy
Intimacy, in a clinical sense, has to do with the amount of self-disclosure exists in
a relationship (Robson & Robson 1998). As a relationship develops and matures, the
amount of self-disclosure increases and expands. For counseling, self-disclosure is
essential. Self-disclosure must be monitored. Too much self disclosure, prior to
sufficient development of presence and trust, can rupture a budding relationship just as
too little disclosure later in a relationship can regulate it to distant, formal, casual and
atrophying because it lacks depth and richness.
Social presence, mutual trust and adequate and appropriate intimacy or self
disclosure exist on the Internet and are richly communicated through email, chat rooms,
bulletin boards, and multi- user domains. This research (Sproull 1997, Robson & Robson
1998, Barak 1999, Suler 1999, Mantovani 2001, Stanley 2001) is fundamental because
without these factors, counseling could not realistically expect to develop a human
relationship and personal bond needed for a therapeutic alliance to move the therapy to a
satisfactory outcome.
Internet Counseling Issues
Website Security
Counseling room security is a significant concern especially in university teaching
labs and public clinics where sound readily passes through the walls. The problem of
eavesdropping escalates on the Internet. Electronic transmissions are most vulnerable


126
Session 1 Computer-mediated
Goals: To engage the participant in collaborative, cognitive personal growth session
Objectives: To develop rapport with the participant
To clarify the therapy process to be used
To teach text-talk non verbal techniques
To identify and clarify the participants issue-based goal
To collaboratively develop a set of tasks to accomplish the goal
Session 3b Computer-mediated
To continue to develop rapport with the participant
To guide the participant to the survey section of WebCT and verify that
the tech is in the help chat room
To thank the students for their participation


40
Phillips cites extensively. She reported that each group was roughly organized along the
12-step philosophy. Her discussion indicated that she was a participant in the first three
groups rather than a researcher or group leader. She briefly touches on private
conversations (IM), cross talk, advice giving, and anonymity as assets of Internet groups
but there is little research in group therapy to support these as constructive, which she
acknowledged, but saw as a positive difference between in person and on line groups.
Suler (2000) complied a list of ten issues to consider in developing understanding
in Internet groups and communities. These are general considerations about the
uniqueness of the Internet rather than group process constructs.
Unidirectional Information Only
Many Internet using therapists are cautiously waiting for legal issues to be
resolved and are providing only information, advice, or recommendations, but not
psychotherapy. Grohols forced and constrained definition of e-therapy demonstrates this
caution (Grohol 1999b, Grohol 2001), while he is, paradoxically, one of the most
outspoken researchers defending the legality of Internet work (Grohol 1999a).
Unidirectional information is generally health related articles, electronic journals, and
patient information sheets (e g., WebMD.com, MayoHealth.org).
Guidelines for Ethical Practice of Internet Counseling
The need for ethical guidelines to direct the development of Internet
psychotherapy services was recognized by all major mental health organizations almost
as soon as the Internet became commercial. The Health on the Net Foundation published
HON Code of Conduct for Medical and Health Websites (HON 1995). Two years later,
in 1997, the National Board of Certified Counselors published Standards for Ethical
Internet Counseling; and the American Psychological Association published Services by


99
almost equally able to develop or communicate the development in either condition. This
is consistent with the study hypotheses
Table 17: Source table for dependent variable Working Alliance Inventory bond (t)
Sources of Variance Type 111 Sum of
Squares
df
Mean F
Square
Sig.
Corrected Model
1251.611
17
73.624 1.320
.195
Intercept
63658.408
1 63658.4081141.364
.000
Condition
22.037
1
22.037 .395
.531
Gender
556.044
1
5561044 9.670
.002
Ethnicity
49.859
2
24.930 .447
.641
Academic Learning Style
.181
1
.181 .003
.955
Introversion/ Extraversin
29.460
1
29.460 .528
.469
Temperament Learning Style
17.346
3
5.782 .104
.958
Condition by Gender
408.880
1
406.880 mm
.008
Condition by Ethnicity
97.366
2
48.683 .873
.421
Condition by Academic Learning Style
54.961
1
54.961 .985
.323
Condition by Introversion/ Extraversin
67.525
1
67.525 1.211
.274
Condition by Temperament Learning Style
54.236
3
18.079 .324
.808
Error
5744.720
103
55.774
Total
298400.000
121
Corrected Total
6996.331
120
a R Squared = .179 (Adjusted R Squared = .043)
Table 18 Mean and standard deviation for gender by condition interaction
Dependent Variable: Working Alliance Inventory (t) bond
Male
Female
Face to Face Mean =
42.86
Mean = 51.66
s.d. =
8.51
s.d. = 6.69
Computer Mediated Mean =
49.33
Mean = 48.69
s.d. =
7.64
s.d. = 7.27
Working Alliance Inventory Task (therapist!
Analysis of the WAI (t) task sub score resulted in two significant main effects,
condition (F = 4.81, p = .03) and gender (F = 5.87, p = .02). Facilitators reported more
collaborative task development with female participants than they did with male


154
Morgan, R., Luborsky, L., Crits-Chrisoph, P., Curtis, H. & Solomon, J. (1982).
Predicating the outcomes of psychotherapy by the Penn Helping Alliance method.
Archives of Psychiatry, 39 397-402.
Mullin, P. A., Lohr, K. N., Bresnahan, B. W. & McNulty P. (2000). Applying
cognitive design principles to formatting HRQOL instruments. Quality of Life Research,
9 12-27.
Murphy, L. J. & Mitchell, D. L. (1998). When writing helps to heal: E-mail as
therapy. British Journal of Guidance & Counseling. 26 (1). 21-32.
Murphy, M. C. & Archer J., Jr. (1996). Stressors on the college campus: A
comparison of 1985 and 1993. Journal of College Student Development. 37 (1), 20-18.
Myers, I. B. (1962). The Mvers-Briggs Type Indicator. Princeton, NJ: Educational
Testing Service.
National Aeronautics & Space Administration. (2001). NASA's efforts: History
of telemedicine, [web document], NASA. Retrieved 02/17 2001, from the World Wide
Web: http: //www. nttc. edu/t elmed/contrib. html.
National Board of Certified Counselors. (2000). Standards for the ethical practice
of web counseling [web document], NBCC. Retrieved 05/03 2001, from the World Wide
Web: http://www. nbcc. org/ethics/wcstandards. htm.
National Board of Certified Counselors. (2001). The practice of Internet
counseling, [web document], NBCC. Retrieved 08/12 2002, from the World Wide Web:
http://www.nbcc.org/ethics/webethics.htm.
North, M. & North, S. M. (1994). Relative effectiveness of virtual environment
desensitization and imaginal desensitization in the treatment of aerophobia. The Arachnet
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Behaviour Therapist, 3 (2), 68-71.


82
scale of the MBTI that was used in this study. Eysenck developed an
introversion/extroversion scale as part of his three factors biologically based formulation
of personality; however, it is more applicable to a clinical population than the population
of this study.
The MBTI is statistically sound. The phi coefficient for reliability ranges from
.55 to .65 for the introversion/extroversion dimensions; .64 to .53 for the sensing/intuiting
dimension; .43 to .75 for the thinking/feeling dimension and .58 to .84 for the
judging/perceiving dimension. The tetrachoric coefficients are higher, .70 to .81 for I/E;
.82 to 92 for S/N; .66 to .90 for T/F and .76 to .84 for J/P. Reliability is found to
increase with the populations age and intelligence. When the data were converted to
continuous scores the reliability estimates are more consistent at .76 to .82 I/E; .75 to .87
S/N; /69 to .86 T/F and .80 to .84 J/P. (Willis, 1984). Table 11.1 (Myers & McCaulley
1993, pp. 177-206) describes the validity studies correlations between the MBTI and the
Adjective Check List by scales, the California Psychological Inventory by scales, the
Comrey Personality Scales, by scales, the Edwards Personality Preference Survey by
scales, the Emotions Profile Index by scales, the Eysenck Personality Questionnaires by
scales, the Maudsley Personality Inventory by scales, the Jungian Type Survey by scales,
the Minnesota Multiphasic Personality Inventory by validity and clinical scales, the
Omnibus Personality Inventory by scales, the Personality Research Inventory by scales,
the Stein Self Description Questionnaire by scales, the Brown Self Report inventory by
scales, the Sixteen Personality Factor Questionnaire by scales and by second order traits,
the State-Trait Anxiety Inventory by state and trait, the Study of Values by scales, The
Rokeasch Dogmatism Scales, the Opinion, Attitude and Interest Scale by scales, the


53
Rational Emotive Behavior Therapy, can be practiced in three minute segments, to be
repeated several times a day.
Wood (2001) describes the typical CBT length of treatment as brief. One of the
major features of CBT is the relatively short time frame required for change to begin.
Some brief interventions were developed using the CBT approach for a one-time,
several minute session (suitable for application by generalist health workers such as
nurses and general practitioners). She emphasized that even when these extremely brief
sessions are not used, CBT rarely requires more than 6-12 months, which would include
scheduled follow-ups for gain maintenance and stabilization.
Brief therapy mandates that a therapeutic relationship develop quickly, therefore
numerous researchers emphasis the need to carefully select high functioning clients who
have a high level of interpersonal functioning. Seriously-ill clients should be referred for
long-term therapy where development of the interpersonal relationship can be the focus
and goal of therapy. (Safran & Muran 1998) These authors recommended that early
priorities in brief therapy should be to develop the therapeutic bond with warmth, respect
and genuine interest, reminiscent of Rogers. They offered that the therapeutic rationale,
the goals and tasks needed to accomplish that goal, should be laid out in the first session.
They summarize their recommendations metaphorically as part Marcus Welby and part
Sherlock Holmes.
Using Brief Therapy with Undergraduates
It seems reasonable to assume that most college students are high functioning by
virtue of meeting admission criteria and remaining in an environment that requires self-
care and executive functioning. Those who are not high functioning will quickly come to
the attention of the resident advisors, concerned friends and faculty, or the crisis center


159
Wood, C. (2001). Thinking it through Counseling interventions, [web
document]. Connexions NSWHEALTH. Retrieved 01/13 2001, from the World Wide
Web: http://www.ceida.net.au.
Wright, P., & Greengrass, P. (1987). Spvcatcher: The candid autobiography of a
senior intelligence officer. New York, NY: Viking Penguin.
Yalom, I. D. (1995). The theory and practice of group psychotherapy. New York,
NY, Basic Books, Inc.
Young, C. (1996). A kinder, gentler glossary for net neophytes and others [web
document]. Women and Performance. Retrieved 05/12 2001, from the World Wide Web:
http://www.echonyc.com/~women/Issuel7/glossary.htm.
ZBoray, D. (1997V The Unofficial Smiley FAQ: author (web document).
Retrieved 09/06 2001, from the World Wide Web: http://www.newbie.net.


129
Sample of tracking sheet
Tracking record of all volunteers regardless of degree of completion. This record
is meant to account for each volunteer. Fill in the code ED for each volunteer whether
they actually participate or not. Indicate F2F or CMC under condition. Put a check mark
under each session completed. Use the note column to mention anything usually (eg. The
woman who never intended to participate). We need each record so we can determine
drop out rate and such.
tNbr
Notes,
Conta Sche
K Facilitatorcomments
Karticipant haciiitatorcted
duled
sessions surveys
complete complete
surveys
complete
LMC0001
Dan
X
LMC0002
Dan
X
X
3
4
2
finished
LMC0003
Dan
X
LMC0004
Dan
X
X
3
4
2
finished
LMC0005
Dan
X
X
3
4
2
finished
LMC0006
Dan
X
LMC0007
Dan
X
X
3
4
2
finished
LMC0008
Dan
X
X
3
4
2
finished
LMC0009
Dan
X
LMC0010
Dan
X
X
3
4
2
finished
LMC0011
Dan
X
X
3
4
2
finished
LMC0012
Dan
X
LMC0013
Dan
X
X
1
scheduled
LMC0014
Dan
X
X
3
4
2
finished
LMC0015
Dan
X
X
3
4
2
finished
LMC0016
Dan
X
X
3
4
2
finished
LMC0017
Dan
X
X
3
4
2
finished
LMC0018
Dan
X
X
3
4
2
finished
LMC0019
Dan
X
X
3
4
2
finished
LMC0020
Dan
X
LMC0021
Dan
X
X
3
4
2
finished
LMC0022
Dan
X
LMC0023
Dan
X
dropped
LMC0024
Dan
X
LMC0025
Dan
X
X
3
4
2
finished
Sample Screen Shot training
pages


94
27.00, SD =8.63), by almost one standard deviation. This suggests that males were better
able to define tasks needed to achieve their personal growth goals in the face-to-face
condition than in the computer-mediated condition, a finding contrary to expectations.
Female participants seem to develop tasks in collaboration with their facilitator equally
well in either condition. (M = 23.49, SD = 8.93; M = 23.57, DS = 7.43)
Table 10 Source table for dependent variable Working Alliance Inventory (c) Task sub
score
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F Sig.
Corrected Model
1498.521
19
78.870
1.158 .308
Intercept
21142.080
1 21142.080 310.493 .000
Condition
158.147
1
158.147
2.323 .131
Gender
20.758
1
20.758
.305 .582
Ethnicity
60.911
2
30.455
.447 .641
Academic Learning Style
105.094
2
52.547
.772 .465
Introversion/ Extraversin
114.795
1
114.795
1.686 .197
Temperament Learning Style
26.789
3
8.930
.131 .941
Condition by Gender
267.312
1
267312
3,926 .050
Condition by Ethnicity
130.877
2
65.438
.961 .386
Condition by Academic Learning Style
1.544
2
.772
011 .989
Condition by Introversion/ Extraversin
65.358
1
65.358
.960 .330
Condition by Temperament Learning Style
294.627
3
98.209
1.442 .235
Error
6945.380 102
68.092
Total
134398.000 122
Corrected Total
8443.902 121
a R Squared = 177 (Adjusted R Squared = .024)
Table 11. Means and Standard Deviation -Dependent Variable, WAI (c) task sub score
Independent Variable, Gender
Male Female
Face-to-face
M =34.14
M =32.49
S.D. = 8.32
S.D. = 8.93
Computer-mediated
M = 27.00
M =32.57
S.D. = 8.63
S.D. = 7.43


62
functions, and so forth. The result of an MBTI is one of sixteen types that purport to
describe a persons inherent functioning and are used to help people understand why
others respond differently in the same situation. Keirsey and others have focused on
temperament grouping and developed their own variations on the MBTI; however, the
MBTI was used for this study because it provided both the learning style data and
personality trait data discussed below.
Personality Attitudes
Except for those clinicians who practice radical behavioralism, individual traits
play a prominent role in the planning, conduct, process and outcome of psychotherapy.
Jung (1923) was once of the earliest psychiatrists to postulate personality types. He
identified polar attitudes that he called introversion and extraversin. In the MBTI users
manual, Myers (1962, p. 9) describes extraversin as a trait or attitude of people who
like to focus on the outer world of people and activity. They direct their energy and
attention outward and receive energy from interacting with people and from taking
action. She describes introversion as an attitude of people who like to focus on their
own inner world of ideas and experiences. They direct their energy and attention inward
and receive energy from reflecting on their thoughts, memories, and feelings. Eysenck
(1970) suggested that personality is biologically determined and is arranged in a
hierarchy consisting of types, traits, habitual responses, and specific responses. Eysenck
built upon Jungs theory with empirical research, describing a structure of personality
along three dimensions, one of which was introversion-extroversion. Brinegar (1992),
researching the predictive value of the MBTI in counseling outcome found that
extraversion-introversion dimension surfaced as the only single dimension score to be
significantly correlated with counseling outcome. Myers, as early as 1962, suggested


PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING
By
MARTHA LANA BOGARDUS GROBLE
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
2002

Copyright 2002
By
Martha Lana Bogardus Groble

DEDICATION
This study is dedicated to the memory of
George A. Bogardus
1920-2001
Martha Lucille Clark Bogardus
1920-1975
Potato and beef farmers who recited epic poetry at our dinner table,
insisted that we attend school even when the crops needed harvested,
instilled a profound love of learning in their children and
kept the house filled with books.

ACKNOWLEDGMENTS
I wish to express my gratitude to my doctoral committee, James Archer, Jr., Harry
Daniels, David Miller and Linda Shaw who permitted me to develop research in a
fast-growing and little-researched aspect of counseling. Doug Johnson, the WebCT
system administrator was an invaluable resource, problem solver, and unexpected source
of encouragement. James Watson and Alan Pappas provided access and administrative
support at Santa Fe Community College.
Robert E. Groble M.D. provided the financial backing for this project and granted
me leave from office duties to complete it. Kristopher Groble, Loren Groble, and Samuel
McFadden interfaced with the facilitators to make their work easier. They ran errands,
and provided data entry, proofreading, and other computer, management, and clerical
services.
I want to thank the graduate students who facilitated this experiment. Without
them, I could not have completed project of this magnitude. Daniel Pekich, rehabilitation
counseling, and Heather McWilliams, mental health counseling each worked with a large
number of participants and headed the team of facilitators at the University of Florida and
Santa Fe Community College respectively. Lakisha Scott, rehabilitation and mental
health counseling; Lamandra Jenkins, school counseling; Anjanette Todd, school
counseling; Wendy Marsh, rehabilitation counseling; Angela Falcone, mental health
counseling; and Lesley LeBaron, marriage and family counseling were seriously
committed to the students they facilitated and were dedicated to working with a protocol
and theory that might not have matched their own preference. They brought a broad
IV

range of counselor training, personal interest, and racial diversity to the performance of
this research.
I appreciate the instructors who permitted me to use precious class time to recruit
participants and who, in most cases, supported my effort by providing the added
incentive of extra credit to their students Laura McCarthy, Dawn Snipes, Michelle
Murphy, Kitty Fallon, Natalie Arce, Kim Fugate, David Marshall, Keith Carodine, Alan
Pappas, Michael Smith, Joyce Orr, and Paul Stem. I would be remiss if I did not
acknowledge all of the participants who shared issues that were sincere and intimate to
them with their facilitators so that we could learn more about the counseling process and
outcome in cyberspace.
v

TABLE OF CONTENTS
Page
DEDICATION iii
ACKNOWLEDGMENTS iv
ABSTRACT x
CHAPTER
1 INTRODUCTION 1
Scope of the Problem 7
Theoretical Framework 9
Statement of the Problem 14
Purpose of the Study 15
Need for the Study 15
Rationale for the Study 16
Research Questions 17
Definition of Terms 17
Counseling terms 17
Computer Terms 18
Organization of the Study 20
2 REVIEW OF LITERATURE 21
Internet Counseling Basic Constructs 21
Social Presence 22
Mutual trust or trustworthiness 28
Internet Counseling Issues 29
Website Security 29
Legal Considerations 34
Modalities 35
Telehealth/Telemedicine 35
E-mail 35
Chat/Conferencing 36
Multi-modal 39
Unidirectional Information Only 40
Guidelines for Ethical Practice of Internet Counseling 40
vi

Credential Validating Referral Sites
Advantages of Internet Counseling
Disadvantages of Internet Counseling
Cognitive Behavioral Counseling Models
Cognitive Behavior Therapy
Brief Cognitive Behavior Therapy
Using Brief Therapy with Undergraduates
Undergraduate Personal Growth Concerns
Individual Information Processing Differences
Demographic Factors
Learning Style Theory
Academic Learning Styles
Temperament Learning Styles
Learning Style Conceptualization Comparison
Measuring Information Processing
Personality Attitudes
Measuring personality attitudes
Counseling Process and Outcome
Working Alliance
Measuring Therapy Outcome
Application in this Study
3 METHODOLOGY
Statement of Purpose
Hypotheses
Descriptions of Variables
Dependent Variables
Independent Variables
Population
Sampling Procedures
Data Collection Procedures
Instrumentation
Working Alliance Inventory (Client)
Working Alliance Inventory (Therapist)
Outcome Satisfaction Questionnaire
Myers Briggs Type Indicator Form M (MBTI)
Center for Innovating Teaching Experiences Learning Styles Inventory (CITE)..
Demographics
Data Analyses Procedures
4 DATA ANALYSIS
Descriptive Statistics for Dependent Measures
vii
41
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46
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53
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56
57
59
60
60
62
63
64
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66
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85

Participant Dependent Variables Analysis 86
Predicted future use (participant) 88
Level of Computer/Intemet Skill 90
Outcome Satisfaction (Participant) 91
Working Alliance Inventory Total (Client) 92
Working Alliance Inventory Bond (Client) 93
Working Alliance Inventory Task (Client) 93
Working Alliance Inventory Goal(Client) 95
Facilitator Dependent Variable Analysis 95
Outcome Satisfaction Questionnaire 96
Working Alliance Inventory Total (therapist) 97
Working Alliance Inventory Bond (therapist) 98
Working Alliance Inventory Task (therapist) 99
Working Alliance Inventory Goal (therapist) 101
Qualitative Analysis 103
5 SUMMARY, CONCLUSIONS, AND IMPLICATIONS 106
Summary of the Study 106
Limitations 108
Implications and Recommendations 110
Research 110
Clinical Ill
APPENDICES
A FORMS AND INSTRUMENTS 114
Participant Contact Sheet 114
Informed Consent 115
Outcome Satisfaction Questionnaire 117
B FACILITATOR TRAINING MANUAL 120
Table of Contents 120
Logistics 121
Session Structure Guidelines 124
Therapy Plan and Progress Notes 127
Facilitator Checklist 128
Sample of tracking sheet 129
WebCT samples screens 130
Required Reading Study Protocol 132
Required Reading College Student Counseling 133
vin

C COMPUTER-MEDIATED SESSION TRANSCRIPT 134
LIST OF REFERENCES 144
BIOGRAPHICAL SKETCH 160
IX

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING
By
Martha Lana Bogardus Groble
December 2002
Chair: James Archer Jr.
Department: Counselor Education
This study examined the process and outcome efficacy of Internet counseling by
comparing it to traditional face-to-face counseling in an experimental environment. We
recruited 123 undergraduates from fourteen classes in two institutions of higher
education. Students volunteered to participate in three personal growth sessions and
complete five surveys. Ten graduate students were trained to conduct brief cognitive
behavior therapy in personal growth sessions within the research protocol. Facilitators
were trained to use the chat room and survey functions of the Universitys secure remote
classroom system WebCT.
Participants were randomly assigned to the face-to-face or computer-mediated
condition. Facilitators conducted an equal number of sets in each condition but each
participant was seen in only one of the two conditions. The demographic survey was
conducted in the classroom during recruitment while the other four surveys were
completed after the last of the three personal growth sessions in the WebCT survey site,
whether the participant had been assigned to the face-to-face or computer-mediated
condition. Facilitators completed two surveys after each set of sessions.
x

Process efficacy was measured with the Working Alliance Inventory (WAI),
forms client and therapist. The WAI provides a score for total alliance, and sub-scores
for bond, task, and goal, key factors in the development of a therapeutic milieu. Outcome
efficacy was measured with a researcher developed Outcome Satisfaction Questionnaire
with three scales, outcome satisfaction, computer skill level, and prediction of likelihood
of future use of computer-mediated counseling.
The independent demographic variables, age, ethnicity and gender, were collected
from the contact information form completed during recruitment. Learning style
preference was determined using the C.I.T.E. Learning Styles Inventory and the Meyers
Briggs Type Indicator (MBTI). Personality attitude preference introversion or
extraversin was determined using the MBTI.
Significant main effects were found for the academic learning style systems and
for gender. Significant interactions were found for gender by condition indicating that
males reported greater process ability in the face-to-face condition contrary to a study
hypothesis. No significant results were found for age, ethnicity, introversion/
extraversin or research condition. Recommendations for further research and clinical
applications are discussed.
xi

CHAPTER 1
INTRODUCTION
At the dawn of the 20th century, the fledgling professions of psychiatry,
psychology and counseling were beginning. As the 21st century begins a radically
different service delivery method, which may in fact generate a radically new helping
profession, is occurring. The current world population of Internet users is estimated to be
around 349 million and growing (Stubbs 2000). A segment of these users are accessing
mental health services variously known as Telecommunications, Telehealth, and
Telemedicine. Telecontact, between a mental health provider and a mental health
consumer, may simply be a plain old phone call, to reassure a patient that his or her
medication has been called into the pharmacy; a copy of an e-mail of a typical interaction
with a troublesome relative, which records the transactions while they are fresh, for
processing in the next scheduled therapy session; peer moderated bulletin board support
groups; video conferencing to train parents how to care for children with seizure
disorders; live, interactive Internet dream work with a renowned dream therapist; or a
very complex, surrealistic virtual reality counseling world. Computer-mediated
counseling is in its infancy. However the generic and programming code necessary to
bring it to maturity is already in place for interactive, graphic (sound, visual, and
animated) virtual worlds where clients can choose avatars or symbols to represent
themselves and to characterize the psychotherapy issues salient to their needs.
1

2
Although the technology and evolution of virtual reality are 30 years old, its
application in counseling has not yet been significantly engaged. The virtual counseling
world is the quintessential postmodern constructionist therapy environment. Fink (1999,
pp. 28-29) reasoned, computer-mediated communication (CMC), clearly a postmodern
phenomenon, are a form identified by the mediator (the computer) as well as by the
communicator (the virtual ego). The machine determines existence. . (u)sing present
technology, CMC tends to be fluid, cycling, and devoid of social cues, which constitute
modernity. Accordingly, psychotherapy that uses CMC is also amorphous, shifting in
response to context, technology and the nature of patient interaction. In essence, the
counselor and client co-create the cyber counseling experience in the material processed -
behavioral issues, distorted thoughts, troubling problems, faulty cognitions,
overwhelming emotions and in the very essence each participant chooses to contribute
to the structure of the working space. Language, spoken or written, forms the connection
between two people. Stanley (2001) argued that rather than language being a reflection
or mirror of social life, language itself constructs social life when it is practiced.
Discourses produce different versions of this social life, different realities. The goal of
discourse analysis then is not to improve upon peoples accounts, but rather to understand
how they are practically achieved.
Much of the power differential between client and counselor dissipates when each
presents without the hallmarks of embodied age, race, gender, physical attractiveness,
size and shape, native language, dialect, speech impediments, or peculiar mannerisms,
which color and may distort face-to-face communication with preconceived stereotypes
and subtle biases. For example, the researcher had a revealing chat experience with an

3
American living in Iceland. This was a personal recreational activity, not a professional
relationship. While both were using an AOL Dream chat channel, the person in Iceland
popped-in to the researchers screen via the private channel (instant messenger) when
the researcher mentioned that she lived in Jacksonville, Florida. The person in Iceland
had moved from Jacksonville Naval Air Station to the Iceland Naval Air Station and was
lonely. The researcher was familiar with both geographic locations, both Naval Air
Stations and with military-family life. The researcher assumed that the person with
whom she was chatting was a young wife of an enlisted sailor. The chat contents were
volcanoes, glaciers, lava beds, hot water lagoons, things to do in Reykjavik, Icelandic
mythology, other exotic locations familiar to both. The researcher terminated the
interaction when she learned that her cyber-friend was a 12-year-old girl. Nothing had
ever been discussed that was inappropriate when talking with a child. Nothing had ever
been discussed that the researcher had not discussed with hundreds of children that age
during her career as a natural history museum curator; however, a personal bias of how,
or when or for what reasons one related to a child had been violated (a surprising
revelation to the researcher). The girl in Iceland had never claimed to be anything other
than what she was a situationally lonely and resourceful kid who moved all too
frequently to become rooted in any conventional community, a person regardless of age
who was interested in relationship, friendship, computer communication and natural
history. One would think that age should not matter in this situation but it did. Most
saliently, it is precisely for this population (the geographically isolated) that telehealth,
telemedicine, and cyber-counseling are most strongly advocated. In the more formal
setting of cyber-counseling, intake information would provide basic information if the

4
client chose to respond accurately. However, in virtual reality one can role play age,
race, gender, physical attributes and try on a vast range of solutions from which to select
practical ideas to apply in his or her social-gravity bound life. The counselor in virtual
sessions will not only be aware that the client may be role-playing but will need to
develop new theory which promotes and capitalizes on a therapeutic world free from
factors that often may actually be the source of the clients distress. This radical new
formulation of therapy may be analogous in the physical sciences to work done in space
in the absence of gravity. Obviously one does not live long in the absence of gravity
without serious physical consequences (e g., loss of bone mass and tissue density).
However, as a special condition to accomplish a specific end (e g., re-growing tissue
more quickly and with less pain) it has therapeutic advantages heretofore unavailable in
theory or in practice. The powerful value of such study is clearly demonstrated by a
global communitys willingness to engaged in the high risk, construction of our third
multibillion-dollar facility for such research the International Space Station (preceded
by Skylab and Mir).
Cyber counseling therapy in the absence of the weight and pressure of social
markers allows a healing space, not a long-term residence for the client. Just as NASA
researchers and their Russian counterparts must experiment and learn about the
weightless environment available in near outer space, mental health researchers must
experiment and learn about the social and relational weightlessness of cyberspace.
Cyberspace then presents the constructionist need for a completely new theory of
counseling, a completely new way of thinking about counseling, not just a new delivery
system.

5
Entering cyberspace, then, disembodies the counselor and the client. In therapy
in cyberspace, the nature of the interaction first deconstructs the everyday givens of the
counselor and client, then the two co-construct a new healing reality through the
therapeutic dialogue. Is that not the crux of psychotherapy helping, guiding,
facilitating, and coaching clients to discover, learn, or experience their story, their inner
dialogue in a new, more self sustaining way? The major mental health professional
organizations (National Board of Certified Counselors, American Counseling
Association, American Psychiatric Association, American Medical Information
Association, American Psychological Association, Commission on Rehabilitation
Counselor Certification) agree that now, in the infancy of Internet counseling is the time
to set the values, ethics and discipline of this new opportunity (NBCC 1997, NBCC 2001,
APA 1997, AMIA 1998, ACA 1999, APA 2001, CRCC 2002).
Virtual Psychotherapy will have as little in common with the theory, context,
content, and outcome of contemporary psychotherapy as contemporary psychotherapy
has with priests and shamans. In the pre-modem or pre-science era, priests and shamans
healed physical, emotional, and spiritual distress based on observations and beliefs about
the natural and supernatural world, using plant materials, astronomical observations,
beliefs about supernatural interventions and such. In the 1990s and 2000s these
ceremonies continue but it is unlikely that Blue Cross Blue Shield or any other third party
payer would assume financial responsibility for a Sufi whirling dervish, a Greek
Orthodox exorcism, a Pentecostal spiritual slaying, an Episcopalian laying on of hands
healing service, a Sunni (Lapland) sweat lodge, a Kiowa medicine wheel, a Lakota
buffalo hide ceremony, Saginaw Chippewa eagle feature ceremony, yogi fire walking

6
treatment, or a Huichol peyote ceremony, even though these practices are far more
ancient and continuous than modern psychology and have anecdotal efficacy (which,
admittedly, is difficult to quantify). In the modem era of scientific understanding and
explanations, physical illness and emotional distress have been dichotomized and
spiritual meaning has been severed from the treatment arena. Postmodern
disappointment with the limitations of science has revisited issues of holistic medicine,
prayer, faith, sympathetic magic (e g., crystals), imitative magic (e g., smoke, feathers)
and worldview in the relief of distress. The same is projected for the postmodern era and
cyber counseling.
Notably, all pre-modem and modern treatments recognize the value of a helping
relationship between the helper and the person seeking help, and a satisfactory outcome.
The outcome must be satisfactory in many or most cases or the method would have
become extinct, or at least superceded by major reformulation (e.g., trepanning to high
technology brain surgery, leaches to lancing).
Disembodied, asynchronous, and globally accessible therapeutic models will
expand the limits of thought and theory about the necessary and sufficient conditions of
therapy and the nature of therapy. Language and overt self expression have always been
the working matter of counseling i.e., Freuds talking cure however, language and
imagination will predominate in cyber counseling and will require new
conceptualizations of the essence of language in a polyglot world community (Shotter
1993). The language of the Internet is English, American English (Fink 1999). English is
the lingua franca of commerce and science. Internet therapy were influenced, limited and
contaminated for clients whose native language is not English even though they may

7
have learned English in a country or culture that places high value on knowing English
and teaches it beginning in first grade.
English as a second language has been identified as a multicultural issue in
counseling. How much greater will this issue become, in a global environment?
Counseling laws, where they exist, tend to confine counseling to the state of the
therapists licensure; however, there are no International constraints. A potential client
can be asked to affirm that she or he lives in the state of the therapists licensure.
However that does not mean that the person does, or if he or she does that he or she lives
in an acculturated community. If a persons English or Spanish appears to be adequate to
the counseling demands, can we assume that the person is keying in his or her comments
directly through the computer, or is the client talking to a typist who enters the
comments, or to a translator who must interpret both sides of the communication
inadvertently and subtly changing each side. Web cam technology offers some solutions,
or hope for solutions to the disembodied and perhaps linguistic problems posed in
Internet counseling. An area of counseling is likely to evolve in the virtual reality model
that is independent of physical and verbal cues.
Virtual reality models and virtual reality role playing have 30 years of history and
refinement from the worlds of virtual gaming and virtual socializing. Fundamental issues
of human presences, viability, efficacy, ethics, limitations, indications, contraindications,
national and international licensing and liability and risks to clients must be thoughtfully
discussed, debated and researched.
Scope of the Problem
Psychotherapists are using the Internet to provide a full range of mental health
services. Powell (1998) surveyed licensed Internet counselors listed on the Metanoia

8
website. She learned that the 13 respondents served 445 clients in 1995, 947 clients in
1996, and 1344 clients in 1997. Over 15,000 health care related web sites were reported
in 2000 (Dunaway 2000). While many of these are telehealth and referral, if only 5% are
counseling and therapy sites, and if 1997 statistics are applied to that 5%, nearly 100,000
clients are presently receiving mental health services via the Internet in the absence of
empirical data to support the efficacy of this service. Of Powells respondents, 85%
primarily used email for their Internet service; however 33% of these counselors had chat
capability and none were using virtual reality technology. These figures do not include
peer-moderated electronic bulletin board, peer-moderated chat rooms and private
messages.
Counseling issues included relationship issues, depression, family issues,
substance abuse, and anxiety (Powell 1998). In 2001, the organizers of the
HealthyPlace.com website both list and recruit mental health professions, creating a
network of referrals and some measure of credential verification. Members are
encouraged to provide supervised web sites, called communities, in the areas of abuse;
ADD/ADHD; addictions; alternative mental health; anxiety and panic disorder; bipolar
disorder; chronic pain; depression; dieting; eating disorders; gay, lesbian and transgender
issues; obsessive-compulsive disorder; parenting; personality disorders; relationship; self
injury; and sex/sexuality. Partners are encouraged to manage a complete website, write
a topic specific column, be the communitys ask-a-doc columnist, maintain a
journal/diary, manage an e-zine or write an Internet newsletter. Holmes (2001) whose
screening appears to be more selective, has links to over 700 counseling sites The owners

9
ofPsychnet.com sell mental health related domain and the tools to develop them at
http://www.psvchnet.com.
Concerned professionals began researching the Internet services, even before the
Internet became available to the public in 1994 (Colon 1994). Professional organizations
have been debating salient issues (Holmes 1997). The federal government has passed a
telehealth bill (U S. Congress 1997, HCFA, 1996, HCFA, 1999). In 1997 the state of
California enacted the first state law restricting California therapists to in-state Internet
clients (Maheu 2001). The American Counseling Association researched current practice
in distance learning related to mental health and cyber counseling. A major
recommendation from that study was the need for research in the area of cyber
counseling (Brown & Walz 2000). Cyber counseling research must build the theoretical
foundation and constructs of Internet communication and of mental health counseling.
Theoretical Framework
The theoretic framework for this study consists of the constructs of social
presence, (Lombard 1997, Reid, 1994), trustworthiness (Edwards 2000) and intimacy
(Robson 1998) in cyberspace, counseling in cyberspace, person centered alliance building
skills, brief counseling, learning styles, and personality traits. Psychotherapy is a human
relationship that heals (Suler 1999). For a relationship to develop both participants must
be involved in a personal, dynamic manner. Earliest theories of the Internet as simply an
impersonal source of information were quickly replaced by the information foraging
cognitive model (Priolli 1999), the sociological gathering and communicating model
(Sproull 1997) and the anthropological expanding human experience. understanding
artifacts, and culture model (Mantovani 2001) to better reflect the evolution of Internet
use and the experience of Internet users. The Social Presence Theory is a micro theory

10
that identifies six components of social presence, a prerequisite to interpersonal
relationship on the Internet and, therefore, a prerequisite to Internet counseling social
warmness, realism, transportation you are there, we are there, perceptual and
psychological immersion, social actor within the medium, and medium as social actor
(Lombard 1997). Almost all counseling theories emphasize the importance of the
interpersonal relationship between the counselor and the clients, although they may vary
in the manner in which they deal with the helping relationship, transference, counter
transference, or working alliance. It is reasonable then to infer that social presence is a
key concept for the development and evaluation of Internet counseling. It should be
noted that several projects have attempted to create computer-as-counselor (Wizenbaum
1966, Maes 1995, Ookita, 2001). However, this study examines the human counselor
client interaction with computer as communication mediator. Computer-mediated
communications is not, in and of itself, psychotherapy, no matter how personal,
rewarding, helpful and satisfying it may be. Hampton and Houser emphasized that the
Internet is a tool and it has no more inherent ability to cause harm than a telephone. Like
other tools, if we use it properly, it will be helpful and beneficial. However, if we misuse
it, the consequences will be detrimental (Hampton 2000). A century of research and
application have demonstrated that psychotherapy is a particular form of communication
supported by heuristic theory, discrete techniques, and demonstrable outcome results.
Now research must do the same for computer-mediated communication so that Internet
counseling will be helpful and beneficial rather than detrimental.
This study was designed to contribute to that needed body of research. To do so,
the study compared brief cognitive behavioral theory applied in personal growth

11
sessions used in two conditions, face-to-face or computer-mediated sessions. Cognitive
behavioral theory defines and describes salient constructs as cognitive events, cognitive
processes, and cognitive structures (Meichenbaum 1988, Meichenbaum 2000). Cognitive
events are conscious, identifiable or readily retrieved thoughts, images, and
accompanying feelings. These events include internal dialogue, expectations, espoused
beliefs, and appraisals. Cognitive events occur when the persons automatic behavior is
interrupted, when one is uncertain about making a choice or judgment, when one is
troubleshooting, and when one is exercising recall or reconstruction of an event or idea.
Cognitive processes are defined as the way a person processes information.
These processes include information storage, search, retrieval and application. Cognitive
theory suggests that information is received, encoded, stored, retrieved and applied to a
given situation based on the beliefs and values of the individual. That is, not all possible
information, which one encounters, is stored or retrieved. There is a selection process
based on salient beliefs and values. An artist, for example, may store shape, form, color,
light, and texture information extant in the everyday world, which others would miss
entirely. The artist can retrieve that information in another setting because it is relevant
to his or her worldview. At least three of these cognitive processes, confirmatory bias,
mental heuristics, and meta-cognition, are important in psychotherapy. Confirmatory
bias is a process by which the person stores and retrieves information that confirms a
belief or value without questioning the underlying belief. Using this process, the
individual filters out any contrary information or ambiguous information, denying that
individual necessary information in the current situation. Mental heuristics are processes
or templates for making decisions in ambiguous situations. Stereotyping is a common

12
mental heuristic. Meta-cognitions are ways of thinking about and controlling cognitive
processes. Scarlett OHaras tomorrow is another day or little orphan Annies the sun
will come out tomorrow are meta-cognitions, cognitive processes or templates that
automatically inform that believer to ignore todays disappointments, fears, worries, and
concerns because they were gone tomorrow. Cognitive structures or schemes are
templates that are pervasive, readily accessible, and reflect personal themes.
Each theory of psychotherapy has generated techniques or procedures, that use,
operationalize, and/or apply the theory in concrete situations with particular clients. Beck
and his colleagues (Beck 1979) emphasized that cognitive behavioral therapy is
collaborative work, which begins with rapport. To develop this working relationship,
they recommend that a good base for building of rapport is simple courtesy not
keeping the patient waiting, remembering important facts about him, and giving a
sincerely warm (but not effusive) greeting. Maintaining eye contact, following the
content of the patients talk, trying to infer and reflect the patients feelings, and phrasing
questions and comments diplomatically help to build rapport. The choice of words and
labels is important (p. 53). For example, non-productive ideas is preferable to
neurotic, sick, or irrational thinking. The working relationship in cognitive
behavior therapy, however, is more than rapport building, which can be accomplished in
a hierarchical relationship as well as in a collaborative relationship. In a cognitive
behavior therapeutic relationship, the therapist and patient work together to determine
how and what the patient thinks, the basis for such thinking, and the practical benefits
and losses that result from such thinking. The patients unique contribution to this
collaborative effort is to provide the raw data for this inquiry, that is, to report his

13
thoughts, feelings, hopes, dreams and wishes. The therapists special contribution is to
guide the patient about what data to collect and how to utilize these data therapeutically
(p. 54). Other collaborative techniques include authenticating introspective data,
investigating underlying assumptions, setting up experiments, and homework
assignments all of which are conceptualized as making the client his or her own folk
scientist whose research is focused on his or her own best interest, personal problem
solving and successful living.
The process of therapy and the outcome satisfaction as reported by both the
participant and the facilitator were evaluated to determine the efficacy of computer-
mediated counseling. A therapy outcome is related to both what happens during the
therapeutic process and what the participants bring to the process. This study examined
cultural factors and personality traits that the client brings to the therapeutic process,
gender, ethnicity, learning style, and personality traits.
Learning style theory, an operational application of information processing
research, is an important construct that identifies inherent learning strength and examines
differential sensory and social ways in that people prefer to learn and learn most
successfully (Babich 1976). Personality traits or the hard wiring of individual differences
in attitude, response to the stimuli, collection of information from the world and source of
energy and authority were simultaneously suggested by Jung and by the mother daughter
team, Myers and Briggs. Myers and Briggs (Myers 1962) operationalized Jungs theory
in the Myers Briggs Type Indicator (MBTI). Of particular interest in this study is the
introversion/extroversion scale, because Reid (1994) and Fink (1999) each suggested that
computer-mediated communication favors those with an introverted attitude. Jungians

14
have researched temperaments and their contribution to the manner in which people
prefer to learn either in a formal educational setting or in life in general. This more
pervasive learning style was examined as well as the academic specific learning style
developed by the Wichita Public School System. Computer-mediated communication,
computer-mediated social presence, cognitive events, cognitive processes, cognitive
schemas, learning style, personality type, and working alliance are the major constructs
that form the theoretical foundation of this study.
Statement of the Problem
It has long been the sin qua non of the helping professions to Do No Harm.
Clients seek counseling because they perceive it offers hope, help, assistance, and
guidance in a time of confusion, pain, loneliness, or danger. Professional and
governmental agents exist to assure clients that the professional from whom they seek
help is trained, qualified and practicing in a safe and proven manner. Insurance
companies and other third party payers often refuse to reimburse any treatment that is
considered unproven or experimental. When new methods are developed, they must be
reproducible and scrutinized by the professional community to insure that they are safe
and effective. It cannot be assumed that when there is major change in the manner in a
service is provided, the therapy is identical to previously validated methods. Internet
counseling must meet the same standard of applicability and efficacy that is required of
all other modes and forms of counseling. Research must inform clinicians regarding
appropriate selection of clients who are likely to benefit from Internet counseling and
must demonstrate useful theory and techniques in the cyberspace-counseling
environment. One size does not fit all, and one technology certainly does not fit all.

15
Purpose of the Study
The purpose of this study was to compare and contrast the development of
working alliance (Horvath 1993, Horvath & Greenberg 1986, Horvath & Mars 1991,
Horvath & Symond 1991), and outcome satisfaction with traditional face-to-face brief
group counseling and with computer-mediated brief group counseling. The effects of
learning style (Babich 1976) and personality traits were analyzed to determine if potential
differential efficacy of face-to-face or computer-mediated counseling could be predicted.
The study will examine which, if any, specific learning style and personality traits are
predictive of success in one modality or the other.
Need for the Study
Few studies exist to guide psychotherapists who decide to move all or part of their
practice to the Internet. Most of these studies are surveys and other qualitative studies as
is appropriate for developing heuristic for a new area of inquiry (Barak 1999, Colon
1994, Dunaway 2000, Fink 1999, Harris-Bowsbey 2000, Stubbs 2000). Virtual Reality
(VR), the high end of Internet technology is being studied with statistical rigor in the
treatment of phobias (North 1994, Rothbaum 1997), cardiac illness in children (Bers
1997), and chronic pain at a bum clinic (Patterson & Hoffman 2000). Ethics working
papers and guidelines exists to structure Internet psychotherapy (NBCC 1997, ACA
1999, AMIA 1998, APA 1997, Brown & Walz 2000, Holmes 1997, NBCC 2000, CRCC
2001) and there is no dearth of technology and technical assistance to develop and market
Internet therapy. There is however, a critical need for empirical research to analyze
typical Internet therapy after almost a decade of development.
The primary therapeutic use of the Internet appears to be Internet support groups
(King 1998). Because of this widespread use, the American Psychological Association

16
conducted an Internet support group symposium at their annual convention. Barak and
Wander-Schwartz (1999) report one of the only studies of Internet therapy. They
describe their study as preliminary, warned that its findings should be interpreted with
caution and called for intensive research. Several professional and scientific questions of
relevance include: Is Internet therapy useful, beneficial, satisfactory, and efficacious? Is
Internet therapy harmful? Does Internet therapy immunize potential clients to effective
face-to-face treatment? Is Internet therapy a technology placebo? Is Internet therapy
snake oil? Do the personality traits of the client influence the effectiveness of Internet
counseling? Is the Internet, as one author suggests, revenge of the introvert? Is a
visual learning style more conducive to effective Internet results than a verbal learning
style? Does the physical isolation of computer-mediated psychotherapy hamper the
success for clients with social group learning style preference? These are but a few of the
questions that need to be considered, especially if the cyber client is to be provided with
appropriate services, the psychotherapist is to remain in compliance with his or her
professional ethics and credentials, and if the insurance industry is to recognize and
reimburse Internet therapy.
Rationale for the Study
This work contributes to the foundation for the lower end technology interface. It
will benefit counselors who wish to work well and ethically Internet. With this and
similar research, counselors will have tools to determine which clients are best served by
Internet counseling, and which clients need to be seen face-to-face. It will benefit clients
who are geographically or situationally isolated from counseling services to be able to
make an informed decision about Internet counseling. Since the federal government
health benefit program has long supported some forms of telehealth and telemedicine as a

17
cost- containment means, a strong research effort is needed to support the claims of
counselors and clients for third-party payment.
Research Questions
The following six research questions were examined in this study:
1. Is brief, Internet counseling as effective as brief face-to-face counseling?
2. Does working alliance develop equally well in brief, Internet counseling and in
face-to-face counseling?
3. Does the information processing style (visualizing/verbalizing) of a
participant influence the effectiveness of Internet brief cognitive counseling?
4. Do personality attitudes (introversion/extroversion) of client affect the
efficacy of Internet brief cognitive counseling?
5. Does the ethnicity of the client affect the efficacy of Internet brief
counseling?
6. Does the gender of the client affect the efficacy of brief cognitive Internet
counseling
Definition of Terms
Counseling terms
Learning style the sensory and social process by which an individual acquires,
encodes, stores, and retrieves information, including visual, verbal, kinesthetic, tactile,
social-individual, social-group, expressive-oral and expressive-written (Babich 1976).
Personality Traits as defined by Jung (1923) these are psychological factions of
thinking, feeling, sensing, and intuiting, which interact with attitudes of introversion and
extroversion. Myers (1962) added the constructs of judging or perceiving (cf. MBTI).
Each individual has preferred functions and attitudes that he or she generally prefers to
use to collect information about, and interacts with his or her intrapersonal and
interpersonal environment.

18
Working Alliance the therapeutic relationship that develops in the counseling
environment to facilitate success. Three components of the working alliance are the bond
between client and counselor, mutual agreement on the goal of therapy, and mutual
agreement on the tasks of therapy that will accomplish the goal (Bordin 1976).
Computer Terms
Synchronous (antonym asynchronous) means happening at the same time or moving at
the same rate of speed or having the same rate and phase as vibrations (Gurainik 1979).
These are key concepts in Internet communication and refer to the ability of people to
communicate at the same time (synchronous) from any computer in the world or near
outer space or to communicate at different times (asynchronous). Examples of
synchronous interactions are text chat and media chat. Email and bulletin board
discussions are asynchronous. (Suler 1999).
Chat real time, live, or synchronous text conversation between two or more people
located at a computer keyboard anywhere on the planet or in near outer space. (Young,
1998)
Cyberspace a term coined by science fiction writer William Gibson (1984) to describe
the space that exists between people, computers, satellites and phone lines
E-mail generally one to one written letters but courtesy copies, blind courtesy
copies, and group mailing are also common (Young 1998).
Encryption applying mathematical algorithm to plain text to produce apparently
unintelligible text for security purposes during transmission (Smith 1997).
Telehealth/telemedicine developed originally by NASA (2001) in the early 1960's to
provide health care and monitoring for astronauts, beginning with Project Mercury. It

19
provides assistance in disaster stricken areas throughout the world and applies space-
based technology to terrestrial medical care.
URL the address or location of information on the Internet. The acronym stands for
Universal Resource Locator (Young 1998), although Berner-Lee (2000), a particle
physicist who created the World Wide Web, originally used URI for Uniform Resource
Identification and the terms are often confused because the URI is still used for addresses
on the Internet outside the worldwide web. The URL of a popular search engine for
example is http://www.google.com. While most clients will see the URL, the direct form
is http://216.199,19,139/ the URI of a small business in Jacksonville. An email address is
not a URL or a URI but rather a hyperlink to a section (bin) within the service providers
website.
Virtual Reality (VR) immersion technology currently being used at MIT and
elsewhere to treat pain and phobias. VR is a graphic and animation rich computer
environment, which simulates visual, auditory and tactile sensations. For
microcomputers, (PCs and Macs) VR uses MOO (MUD Object Orientation) virtual
reality programming code that allows the creation, use, and manipulation of items on the
screen. MUD is Multi-User Dungeons, (now also Multi-User Domains, Multi-User
Dimensions) a virtual world originally developed in the 1970s and 1980s for playing
adventure role-playing games. MUSH is Multi-User Shell, a programming system that
allows users to develop and manage either an adventure or a social MUD (Bruckman
1995). This technology can potentially be used to develop VR counseling from any
computer given adequate bandwidth and baud rate to both the counselor and client
computers.

20
Organization of the Study
This study consists of five chapters, an abstract, three appendices, and a list of
references. The abstract and introduction present the Internet and counseling context for
the study describing research issues of the growth and professional concerns about
Internet counseling. The second chapter reviews relevant scholarly literature on social
presence, Internet counseling, face-to-face brief counseling, working alliance measures,
outcome efficacy measures, learning styles and personality traits. The third chapter
describes the structure of the study, characteristics of the participants, dependent and
independent variables observed, measures used, and statistical procedures applied to
analyzing the results of the experiment. Chapter four presents the statistical results and
chapter five discusses the significant results, potential impact to Internet counseling,
limitations of the study, and recommendations for Internet counseling and further
research. The appendices contain forms and measures created for this project, protocol
for facilitator training and sessions, and a sample computer-mediated session transcript.

REVIEW OF LITERATURE
The relevant scholarly literature is reviewed in this chapter. Topics to be reviewed
are research; Internet computer counseling concepts; Cognitive counseling theories;
personality traits; temperament learning style; academic learning style, and counseling
outcome and process theory. The exiting Internet research, which is primarily qualitative
and heuristic, addressed the social and cultural dimension of Internet transaction and the
construct of social presence on the Internet, a prerequisite to counseling. The advantages
and concerns about Internet counseling as discussed by the mental health professional
organizations and activists, and current applications of counseling on the Internet. While
outcome efficacy of Internet counseling is a concern in all theoretical approaches, for the
purposes of this study, the theory used is brief cognitive behavior therapy. Research
regarding basic precepts of cognitive behavioral therapy, basic precepts of brief therapy
and the construct of working alliance are reviewed. Relevant research about personality
traits, theory and application of learning styles are discussed as related to independent
variables in this study. The theory and instrumentation for evaluating the independent
(personality type and information processing style) and dependent (working alliance and
outcome) variables are presented. This chapter concludes with a discussion of the
contribution of the existing research to the formulation of the present study.
Internet Counseling Basic Constructs
To counsel in cyberspace, one must first assess the constructs and theories
defining human relations in cyberspace. Counseling is a human interaction, which is a
21

22
good deal more complex than ordering a book from Amazon.com or a rose bush from
JacksonandPerkins.com. Is there a subjective component to human interaction in
cyberspace? Is there a person or psyche to counsel? Three major concepts have
been discussed at length social presence, trustworthiness and intimacy. These factors
create an environment in which a therapeutic alliance can be developed. One of the three
essential components of a therapeutic alliance is the development of a personal bond.
Social presence, trust, and intimacy or self-disclosure, create the milieu in which a
personal bond can develop between the therapist and client. The client and the counselor
need to experience a sense of bond, connection, or rapport. The bond can be based on
the sense of mutual trust, liking, understanding and care (Bordin 1976, Horvath &
Greenberg 1986).
Social Presence.
Is there social presence in cyberspace, and if so, how does it manifest? In
response to the gamut of pressures emanating from the war in Viet Nam and the Cold
War, government, military and related universities developed the technology to deliver
information around the world and into near outer space almost instantly. At the same
time, social, political, humanitarian and radical thinkers were developing experiments in
human living that were just as dramatic. The social geniuses of the era readily adapted
and defined the ultimate use of the Internet. Rheingold (1994) was perhaps the first
social thinker to systematically describe the social and cultural communities that
developed on the Internet. The WELL, a San Francisco founded, Internet community
dating from the early 1980s, grew out of the social activism, communal living
experiments, and democratic philosophies of the 1960s. The personal involvement and

23
real life connection among members is illustrated in the following two incidents. The
WELL community organized a massive medical resource location, medicine delivery,
and member return transportation from India to San Francisco when a former member
who had become a Tibetan nun developed a rare liver condition and was destined to die
in India without this heroic, real time, real cash, real resource, unbidden, but greatly
appreciated massive intervention (28-32).
In another case, a prolific member of the WELL committed Internet suicide, the
act of removing all of his years of comments and conversations written into the fabric of
the community. Alert members of the community called him, assured that he sought and
received professional help, and notified his family and other friends. In the end, the
effort was insufficient and the member committed real world suicide. Rheingold mused
Suicide brings up unusual feelings in any family or
social group. Fortunately, there were one or two
among us who knew exactly how to understand what
was happening to us: a fellow who had struggled with
years of feelings over his brothers suicide was able to
offer wise and caring and credible counsel to many of
us.
There was a real-life funeral, where we brought our
physical bodies and embraced each other and Blairs
family. We were learning how fond we had grown of
Blair, and how his death put a milestone in cyberspace.
Marriages had happened and others had unraveled.
Businesses had started and failed. We had parties and
picnics. But death seems somehow more real, even if
your only participation is in the virtual funeral. How
could any of us who looked each other in the eye that
afternoon in the funeral home deny that the bonds
between us were growing into something real? The
feelings ran just as high during the virtual part of the
grieving rituals as they did during the face-to-face part
- indeed, with many of the social constraints of proper
funeral behavior removed, the Internet version was the
occasion for venting of anger that would have been
inappropriate in the face-to-face gathering. There

24
were those who passionately and persistently accused
the eulogizers of exhibiting a hypocrisy that stank unto
the heavens, because of our not altogether charitable
treatment of Blair Internet when he was alive.
Those of us who had made the calls to Blair and his
shrinks, who went out and met his brother and his
mother and tried to provide them some comfort, had a
different attitude toward those who couldnt bring
themselves to attend the painful event in person but
didnt hesitate to heckle others Internet. People who
had to live with each other, because they were all
veteran addicts of the same social space, found
themselves disliking one another (p. 37).
And...
There has always been a lot of conflict in the
WELL, breaking out into regular flamefest of
interpersonal attacks from time to time. Factionalism,
Gossip. Envy. Jealousy. Feuds. Brawls. Hard feelings
that carry over from one discussion to another (p. 53).
Thought, feelings, and behaviors are the raw materials of counseling.
Rheingolds experiences provide poignant insights into the thoughts, feelings and
behaviors Internet and in the real life of a multinational, Internet, social community.
From social psychology, the construct of disembodied engagement and personal
interaction over the Internet has been named presence. Lombard and Ditton (1997)
identify presence as the sense that mediated experience (computer, simulation rides,
home theater, video conferencing) is natural, immediate, direct, real and unmediated.
This qualitative factor of mediated communication is crucial to community building and
counseling. An enhanced sense of presence is central to the use, and therefore the
usefulness and profitability, of the new technologies... These technologies either are now
changing or are expected soon to change many of the ways we work, play and live (p.
2). Social presence theory was studied early in the advent of mass, affordable access to
electronic media and continue to be important in social psychology and mass
communication research.

25
Cyber feminist Plant (1996) warned that the Internet disembodies, degenderizes
and promotes yet another form of oppression. Stanley (2001) and others (McLuhan &
Friore 1967, Billig 1996, Shotter, 1993, Turkle, 1995) countered that language embodies
the authentic self and depoliticalizes the communication. Stanley disputed the concept of
virtual space saying, a social space (is) constructed through which embodiment could be
revealed. This reality is real space, the space that is on the other side of the screen ...
real space constitutes the embodied practice of social talk (p. 77). He suggested
interpersonal life is a dynamic performance of language constructed in speaking and
writing, not in thinking or holding unexpressed opinions and attitudes. Rather than
language being a reflection or mirror of social life, language itself constructs social life
when it is practiced. Discourses produce different versions of this social life, different
realities (p. 79). Stanley works with international students for whom life with family
and friends of necessity is text based. He analyzed the text-based interviews with distant
students/participants and identified recurring themes. Quotation marks are used to signal
stake and accountability. Subjectivity and reality, marked by the use of humm and
erm, Stanley noted is an archetype of phonetic space (that) has been appropriated for
use in cyberspace (p. 86). He found that the bodily presence of the person using the
Internet is present in the use of emoticons (emotion icons) and by typing speed, pauses,
and deletions. Language itself embodies in metaphorical phrases. Boechler (2001)
makes much the same argument from a cognitive process and concept point of view.
Much of the debate over presence and embodiment (Harris-Bowlsbey 2000, King
& Moreggi 1998, Laszlo, Esterman, & Zabko 1999, Miller 1995, Plant 1996, Powell
1998, Reid 1994, Suler 1999, Walther 1996) has or needs to examine how presence,

26
emotion and embodiment are incorporated in text-based communications. Letters,
missives and discourses were the major form of communication from the invention of
writing at least as early as 5,000 B.C.E. until the invention of the telephone, telegraph,
and radio in the last 19th century (Bell 1867, Bell 1895, and Marconi 1900). The most
common and wide spread convention for expressing emotion on the Internet is the smiley
or alternately the emoticon. Early on, the need to encode and covey feelings was
recognized in the computer chat space. Carnegie Mellon Principal Research Scientist,
Scott Fahlman, (1995) admits
Yes, I am the one who first suggested the use of the :-)
and :-(glyphs in E-mail and bboard posts sometime around
1981. People were making sarcastic comments in posts,
others were taking them more seriously than they were
intended (no body language on the net), and silly arguments
were breaking out. So I suggested on one of the CMU
bboards that people explicitly label comments not meant to
be serious with a :-) glyph. Very quickly, this idea spread
all around the world and others started creating clever
variations on the theme. The awful term emoticons is
much more recent.
These glyphs (see ZBoray 1997) are an important part of routine Internet
socializing but are inadequate for expressing the range of non-verbal cues necessary in
counseling. Other rules of appropriate behavior (netiquette) on the Internet also evolved
to smooth social interactions (Rinadli 1998) and should be observed by the cyber
counselor but like glyphs, netiquette is not sufficient for the needs of the counseling
relationship. The introduction and development of glyphs and netiquette demonstrate
that the need and convention was recognized early in the development of text-based
communications.

27
Cyber counseling specific conventions have been developed and need to be
researched, developed, enhanced and expanded. Murphy and Mitchell (1998) developed
a three-component convention to provide a text-based alternative to the non-verbal cues
in traditional counseling. Technique 1 is called emotional bracketing. In the text of an
email or other text-based communication, the writer puts the emotional tone of his or her
thought in parentheses (p. 24). For example, a therapist may be concerned because the
client mentioned his car was stolen then skipped without elaboration to another topic.
The therapist might write. Let me interrupt here and return to your mention of your car
being stolen (concern, puzzled). What have you had to do as a result. . police, public
transportation, . .? I know you frequently have to take your aunt to doctors
appointment (proud of your commitment)? How are you coping (knowing you have)?
The second tool or technique Mitchell and Murphy developed is called
alternatively textual visualization or descriptive immediacy. They provided the
following example:
If you were standing beside me as I write this, Tanya,
you would notice me stopping often, falling back against
the back of my chair saying thats incredible to myself.
Your recent successes against guilt are so wonderful that
even now I find myself (right now!) Stopping in the
middle of the sentence, my hands towards the computer
screen, my mouth wide open as if to say this is amazing.
How did she defeat guilt? (p .24).
Third, Mitchell and Murphy encouraged the conscious, deliberate use of literary
tools simile, allegory, metaphor, poetry, story telling, and mythology commonly used in
face-to-face therapy. These techniques have expanded the repertoire available to
therapists well beyond the effective but static emoticon or smiley, for expressing

28
emotional context, for making content explicit and for making the here-and-now process
comments so vital to counseling, in text talk.
Another equally interesting concept is hyper-personalization. Walther (1996)
introduced the concept of a reinforcing feedback loop, which he called an intensification
loop. He suggested that a person can project his or her idealized self into the
communication and be reinforced for that idealized self, increasing the realization of that
ideal in their daily off computer life via ego strengthening. He also suggests that when
communicators do not have to pay attention to social cues they pay more attention to the
text and its meaning. He did not, however, discuss whether this enhances or distracts
from therapy.
Patterson (2000) and Riemer-Reiss (2000) each reviewed Internet rehabilitation
service delivery and concluded that the Internet offers accessibility, immediacy,
advocacy, and competency for rehabilitation counselors and their consumers and also
challenges and ethical considerations. Patterson mentioned the availability of vocational
information, Department of Labor Statistics, job banks, placement resources, medical
information, free or inexpensive assessment tool (e g., Keirsey Type Indicator, Career
Interest Game, Career Key, Birkman Method Career Style Summary and the Self
Directed Search), support groups and continuing education. Patterson advised
judicious use to complement the work of human interaction.
Mutual trust or trustworthiness
Trustworthiness, consisting of dependability, reliability and honesty, is essential
to a good counseling relationship (Ainesworth 1995). These mirror the qualities Rogers
(1957) included in what he considered necessary and sufficient conditions for person
centered therapy to be effective. Trustworthiness, on the Internet has been researched by

29
Cheskin Research and Studio Archetype/Sapient (1999 because of it is vital component in
ecommerce. Web site and email security were discussed in length below because
cyberspace is mysterious to many users and because privacy, confidentiality and
credibility are essential factors for instilling a sense of trust.
Intimacy
Intimacy, in a clinical sense, has to do with the amount of self-disclosure exists in
a relationship (Robson & Robson 1998). As a relationship develops and matures, the
amount of self-disclosure increases and expands. For counseling, self-disclosure is
essential. Self-disclosure must be monitored. Too much self disclosure, prior to
sufficient development of presence and trust, can rupture a budding relationship just as
too little disclosure later in a relationship can regulate it to distant, formal, casual and
atrophying because it lacks depth and richness.
Social presence, mutual trust and adequate and appropriate intimacy or self
disclosure exist on the Internet and are richly communicated through email, chat rooms,
bulletin boards, and multi- user domains. This research (Sproull 1997, Robson & Robson
1998, Barak 1999, Suler 1999, Mantovani 2001, Stanley 2001) is fundamental because
without these factors, counseling could not realistically expect to develop a human
relationship and personal bond needed for a therapeutic alliance to move the therapy to a
satisfactory outcome.
Internet Counseling Issues
Website Security
Counseling room security is a significant concern especially in university teaching
labs and public clinics where sound readily passes through the walls. The problem of
eavesdropping escalates on the Internet. Electronic transmissions are most vulnerable

30
to security breaches at their origin and at their destination. In transit, the message
consists of binary code that has been broken into several packets each of which travels
the Internet independent of the other. At the destination, they are reassembled and
checked for completeness.
Security should be applied at each end point where the message is complete and
readable but the counselor can only control his or her end of the communication. It
seems obvious that therapy should not be conducted from the clients employers
computer or from a public computer (library, computer caf, etc.). Ironically, these sites
may be the clients only Internet access. Law and legal intervention cannot secure
wireless connections to the Internet. Hardwired cable modems or DSL cables are also at
risk because they establish a permanent address for the computer access rather than a new
one with each dial up making the connect susceptible to deliberate attack. Dial up
connections are vulnerable to disruption of service. The client and therapist each have to
be responsible for common sense and security on their respected ends of the transmission.
Grohol (2001), who credits himself with creating the term e-therapy, claims that
e-therapy is more confidential and secure than traditional psychotherapy citing thin
walled clinics, and patient charts available to clerical personnel as evidence of lack of
security in a traditional office or clinic. Grohol does have a point to the extent that unless
a therapist sound proofs his or her therapy room, encrypts all telephone calls to
patients/clients, and checks the office regularly for surveillance devices, does his or her
own transcription, copying and filing, and so forth, most Internet psychotherapy is as
secure as its face-to-face counterpart. Workers Compensation required that all case notes
relevant to the injury be copied and submitted with the request for payment. How secure

31
is that? Physical security is the most crucial place to insure office or Internet privacy and
confidentiality. (Smith 1997) In recent spy scandals, the main issues involved missing
disks, missing laptop computers, and missing hard drives, not Internet or Intranet
security.
Encryption (Smith, 1997) offers the second mode of protecting Internet privacy
but has no application if one uses a cell phone or wireless Internet connection (encryption
is legally defined as a munitions in the USA and 40 other countries). Ironically, it is the
geographically remote who rely on wireless communication. The average user can
connect to the Internet in one of three ways. Dial-up connections use regular telephone
lines. In remote areas, some telephone lines still use analog (rotary, pulse) system and
cannot dial up an Internet Service Provider (ISP). Television cables offer another way to
connect to the Internet, but cable television is likewise not economically feasible for the
companies in remote areas and therefore not available to one of the most under served
populations. Dish satellite is available in remote areas but because it is wireless, it cannot
be legally encrypted. Most high-speed Internet connections rely on microwave towers
and as a result are wireless even when offered by the local telephone carriers. Cable
high-speed Internet connections are probably the only DSL connections that use physical
wire. Internet security is a matter of therapist knowledge and proper application of both
hard ware and software solutions (Smith, 1997). T-4 lines are the most secure, most
expensive, and least available to the average therapist. Furthermore, even if the therapist
has a secure high-speed connection, the actual communication between a therapist and
client can only proceed at the rate of the slower system.

32
The issues for email, chat, and bulletin board security include authentication, non
repudiation, public key distribution, and mailing list handling (Smith 1997, p. 287-296).
Authentication asks who wrote the message did the therapist write the message the
client receives, did the client write the message the therapist received. Non-repudiation is
important in legal matters, commonly business contracts but, for the therapist and client
in potential lawsuits divorce, custody, criminal, and malpractice. Public keys are
passwords and other encryption devices use to allow discretionary access to information.
Mailing list, (e g., listserv, USELIST) are difficult to encrypt because the decryption must
be specific for each receiver.
Cryptography and secret codes has a long history in government, intelligence and
military use but equally if not more importantly in business and commerce. Modem
cryptography has been spurred by the business and commercial needs of the Internet and
by major advances in modem mathematics that provides the means to develop nearly
indecipherable code algorithms. The therapeutic community is rightly concerned about
privacy and confidentiality. However, hacking or breaking into a properly secured
computer system, is actually very difficult, rare and targets valuable and marketable sites.
With this caveat, the therapist is wise to encrypt his or her site for the protection of the
therapist/client communication and use a third party secure payment company, which
specializes in the coding/decoding in monetary transactions. This protects both the
therapist and the client from external credit card fraud, exploitation, and subterfuge. It is
the most complex, expensive and restrictive form of encoding. Companies exist to
handle financial transactions because the ordinary transactions of many businesses are
not worth the time and trouble required to intercept or forge them. It is a much better

33
business strategy to hire out secure credit card processing than incurring the expense and
risk of doing it in-house.
Mitchell and Murphy (1998) recommend that all e-mail be encrypted but agree
that it may be too anxiety producing to ask of a client seeking professional help to acquire
and learn to use an encryption program (p. 52). E-mail can be encrypted with free or
inexpensive software but it only works if it is installed and used properly. PGP (Pretty
Good Privacy) encrypts both e-mail and files for a one-time cost. The software plugs
in to common email programs such as Endora or MS Outlook, to encrypt files, disks and
existing email on a hard disk. ZixMail is a secure email application, which downloads
free but requires $1 per month payment. Zip-Lip and HushMail are both free secure web
messaging services. Messages remain on the server so they cannot be intercepted.
Nothing is stored on the clients computer or the therapists computer (HON, 1995). The
major concern about the use of encryption software is not the quality and usefulness of
the software, but the misuse or inappropriate use of the software (Smith, 1997).
The electronic security issues, technological failures and access have as long a
history of research and development as do research on therapy relationships and outcome
efficacy (Wright & Greengrass 1987). Electronic security is directly related to ethical
issues of privacy and confidentiality. While news media seem to frequently report
breaches of electronic security, a close examination of recent espionage incidences reveal
that most involve an insider (Lee, Ames, Hansen) who has direct, physical access to the
hard drive, server, stolen laptop, software, encryption/decryption devices or paper files.
Virtual Private Network (VPN) is the concept of using private computers (desktop,

34
laptop, mainframe or server), firewalls, public servers, the Internet and the clients
personal computer (Barlow 2001, Fratto 2000).
Certification authority issue digital signatures after performing background
checks to assure that the company certified is what it claims to be. The personal digital
signature certificate verifies that the user is who he or she claims to be. Loss or misuse of
a digital signature certificate has serious consequences, comparable to loss or misuse of a
passport. A digital signature is also analogous to a business or occupational license and
bonding.
Legal Considerations
State licensure and states rights are the key legal issues in Internet psychotherapy.
Federal and state laws regulate Telemedicine (Congress 1997, HCFA 1996, HCFA 1999).
Interestingly, both California and Minnesota have passed laws allowing reimbursement
for telehealth services (Jones 1996a, Jones 1996b). California (Maheu 2001) has also
passed an Internet psychotherapy law restricting practice to in-state clients. Case
Managers, rehabilitation counselors, and nationally certified counselors in states without
licensure may be relatively safe practicing under their national certification. There is
ultimately no way to know if the person with whom the therapist is communicating is
physically located in a state or nation where the therapist has a license or certification.
As a result, much of the experimental research on Internet psychotherapy is being
conducted in Israel (Barak 1999, Barak & Wander-Schwartz 1999), Australia (Reid 1994,
Smith 1997), and Canada (Murphy & Mitchell 1998, Mitchell & Murphy 1998).
Dunaway (2000) discusses both jurisdiction and malpractice insurance issues
The potential for out-jurisdiction counseling is another hurdle faced by e-therapy. State
licenses restrict providers to practice within a state, but patients on the Internet can reside

35
anywhere. This is an unsettled area, so it is smart to take a conservative approach until
further guidelines are developed. She advised, generally speaking, unless there is a
specific disclaimer in the insurance policy, the carrier would have difficulty denying
coverage for malpractice claims for work within the scope of mental health treatment by
a licensed psychiatrist. Therefore, a licensed professional may be covered for liability
while practicing on the Internet but geographic scope of practice area is a concern.
Grohol however points out, sadly, that licensing boards are infamously inactive in
pursuing complaints and taking action against licensed professions. His advice is to
practice within professional ethical guidelines and within ones expertise and let case law
evolve (Grohol 1999a).
Modalities
T elehealth/T elemedicine
The American government and military interest in the Internet included all
aspects of defense including the health and care of personnel in remote areas.
Telehealth/ Telemedicine is the branch of Internet use and research that provides
electronic healthcare to military and civilian populations who lack readily available
geographic access to medical care.
E-mail
Therapy via e-mail is currently the most widely used form of Internet mental
health service outside Telehealth/Telemedicine, and the most accessible to clients and
therapists. E-mail was an after thought of Internet developers who found it convenient to
communicate with one another involved in a complex project design. It requires minimal
bandwidth and can be accessed with an appliance for those who cannot afford a
computer. E-mail service can be obtained from several free sources.

36
Murphy and Mitchell (1998) developed techniques described above and wrote
about their qualitative observations from conducting therap-e-mail on their web site
http://www.therapvlntemet.ca. They required potential clients to complete and return an
on line form called the Virtually Solve It worksheet, which can be completed offline.
They believed that the permanent record of email makes consultation and supervision
easier. A response can be reviewed by the supervisor, consultant or peer prior to being
sent to the client (p. 26). The permanent potential of email encourages the therapist to be
thoughtful and behave in an ethical manner (p. 27). Clients found that filling out the VSI
and writing out their interactions with the therapist externalized their problems making
them easier to confront and resolve (p. 27). Repeated efforts to obtain this form were
unsuccessful, so it appears no longer to be a viable web service, however GrohoFs site is
active and has pre-therapy form at http://psychcentral.com.
Mitchell and Murphy recommended that further research should be conducted to
study the impact and effectiveness of their techniques (emotion bracketing and textual
visualization (descriptive immediacy); application of narrative and solution focused
therapy in face-to-face and electronic therapy; impact of writing itself in the therapeutic
process; and pre-treatment effect of writing to the therapist (e.g., using the VSI)( p. 30)
Chat/Conferencing
Suler (1997) describes text talk as austere because it lacks voice, facial
expression, body language and visual/spatial environment. While some may find this
disorienting, he suggested that for many, text-talk is a more direct, intimate mind-to-mind
communications approximating an internal dialogue. In his study, Suler analyzed
many megabytes of saved logs exploring the concerns that the absence of visual and
auditory cues confuse users, and lead to painful misunderstanding. He identified

37
phenomena of text-based conversation. There is often a lag in live messages due to
Internet connection speed. He called these out-of-syn occurrences, temporal hiccups.
This can seem similar to talking over another person in face-to-face conversation. The
Internet therapist will need to determine whether he or she is viewing a temporal hiccup
or an interpersonal issue. Most chat modes providers, including AOL and WEBCT (used
in this study), allow for only a line at a time text entry (plus cut and paste for large pieces
of text). Correspondents dont actually see what the other is typing until it is published
using the enter key. ICQ in live mode however allows for a more natural ongoing
conversation limited only by the speed/skill of the typist. Writing is live rather than
written then sent. There is software that allows one speaker to complete a lengthy
thought before the next message posts and was used extensively in Taylors AOL Dream
Group Therapy.
Suler (1997) developed a convention of listening. When one person was clearly
caught mid-sentence or mid-thought by the limitations of the program, others need to sit
back in a listener mode. Some users will even type listening to Joe to indicate this
posture to others (p. 5). He describes staccato speak as a joking around or playful
exchange, a group free for all (p. 6). His illustrations are reminiscent of the Fireside
5 or Monty Python comedy routines ( p. 6). Suler includes acronyms (e g., brb for be
right back) under this category but this researcher tends to see acronyms as more similar
to emoticons, emotion bracketing and other text talk enhancement. The occurrence of
staccato speak (minus acronyms) in psychotherapy could signal anxiety or avoidance
of painful emotions.

38
Barak et al (1999) conducted one of the only empirical studies reported. He and
his team chose synchronic chat groups for their research because e-mail, the most
common form of Internet therapy,
lacks a key feature of human interpersonal
communication characterized by spontaneity, authenticity,
immediacy and directness. This feature is directly related
to the commonly accepted and generally appreciated
therapeutic factor of here and now. Numerous schools of
psychotherapy argued that this immediacy factor may be
responsible to a great degree for dramatic therapeutic
developments. In addition, defense mechanisms or
cognitive distortions (depending on the school of therapy)
are less, likely to take place in a here and now therapeutic
situation, (p. 1)
In this study of brief Internet Chat room group therapy, Barak, recruited 15
students from several Israeli universities and community colleges. Six participants (three
men, three women) were assigned to the Internet condition and nine students (three men
and six women) were assigned to a traditional face-to-face group therapy. Both groups
were led by experienced, female therapists and were brief, dynamically oriented. One
therapist conducted the Internet group while the other conducted the face-to-face group
therapy. The Internet condition was conducted in a JavaScript, password protected chat
room for seven, ninety-minute sessions. The face-to-face group met on the campus of the
University of Haifa. The dependent measures were Measure of Therapy Impact: Self-
Esteem, Social Relationship, and Well-being. Each scale was a 25 item Likert-like scale
but Barak does not cite the source of these measures Moose (1981) developed the group
process measure, a Likert-like evaluation questionnaire designed to elicit opinions about
the Internet group therapy experience. Because of the small number of participants in

39
this study, the data were evaluated qualitatively by analyzing chat room transcripts in
addition to reviewing the results of the dependent measures.
Results indicated that participants exhibited positive support, personal disclosures,
interpersonal sensitively and group cohesiveness. No comparison with the face-to-face
group was reported. Recommendations for further research include a study of
preparation for therapist for Internet therapy, and rules by which such groups should
operate (Barak & Wander-Schwartz, 1999).
Multi-modal
Colon (1994), a prominent social worker, conducted one of the first studies of
Internet psychotherapy. She conducted a three-month study with eight participants using
email, chat and bulletin board. Participants were recruited and screening Internet from
ECHO subscribers. Participants were screened, refrained from in person contact with one
another or Colon, posted/participated actively at least three times a week and participated
for three months. Colons training was psychodynamic and so were her Internet groups.
Her primary concern about the experiment Internet groups was the absence of non-verbal
cues. (p. 9). She concluded In Internet therapy, and perhaps in the psychoanalytic
session, language is action. Nothing happens Internet, or for all intents and purposes,
in therapy. There is no way to quantify what happens in an Internet group. And yet lives
can change.
Phillips (1996) qualitatively compared four groups within which she participated,
an Internet service Adult Children Of Alcoholics (ACOA) chat group, an Internet service
ACOA email list, an Internet ACOA email list and an ACOA chat group she created on
the Internet service. None of these groups appear to be formal groups with regular
attendance, ground rules and on going interaction as defined by Yalom (1995) whom

40
Phillips cites extensively. She reported that each group was roughly organized along the
12-step philosophy. Her discussion indicated that she was a participant in the first three
groups rather than a researcher or group leader. She briefly touches on private
conversations (IM), cross talk, advice giving, and anonymity as assets of Internet groups
but there is little research in group therapy to support these as constructive, which she
acknowledged, but saw as a positive difference between in person and on line groups.
Suler (2000) complied a list of ten issues to consider in developing understanding
in Internet groups and communities. These are general considerations about the
uniqueness of the Internet rather than group process constructs.
Unidirectional Information Only
Many Internet using therapists are cautiously waiting for legal issues to be
resolved and are providing only information, advice, or recommendations, but not
psychotherapy. Grohols forced and constrained definition of e-therapy demonstrates this
caution (Grohol 1999b, Grohol 2001), while he is, paradoxically, one of the most
outspoken researchers defending the legality of Internet work (Grohol 1999a).
Unidirectional information is generally health related articles, electronic journals, and
patient information sheets (e g., WebMD.com, MayoHealth.org).
Guidelines for Ethical Practice of Internet Counseling
The need for ethical guidelines to direct the development of Internet
psychotherapy services was recognized by all major mental health organizations almost
as soon as the Internet became commercial. The Health on the Net Foundation published
HON Code of Conduct for Medical and Health Websites (HON 1995). Two years later,
in 1997, the National Board of Certified Counselors published Standards for Ethical
Internet Counseling; and the American Psychological Association published Services by

41
Telephone. Teleconferencing, and Internet: A statement bv the ethics committee of the
American Psychological Association). In 1998 the American Medical Informatics
Association published Guidelines for the Clinical Use of Electronic Mail with Patients.
The American Counseling Association published Ethical Standards for Internet
Counseling in 1999. The International Society for Mental Health Internet and the
Internet Health Coalition each published their standards in 2000. In 2001, the American
Psychiatric Association published American Psychiatric Association principles for
medical ethics with annotation especially applicable to psychiatry.
In a pilot study, Mitchell and Murphy (1998) examined the email therapeutic
relationship with one client who had engaged in over 100 transactions with the therapists.
In 1995, the researchers had set up a pilot counseling site on the local computer bulletin
board service. They limited access to counseling services to two thousand members.
The services offered were the Virtually Solve It worksheet (VSI) an Internet form design
to help the potential client explore and externalize the problem. They introduced therap-
e-mail and Ask PATtYQ which stood for Professional Answer To Your Question. In
1998 they interviewed the one client chosen for qualitative response to issues being
debated by the National Board of Certified Counselors committee on WebCounseling
ethics security issues, physical absence, emergency situations, technological failure,
therapeutic relationship/efficacy and access.
Credential Validating Referral Sites
Reliability, credibility and freedom have been the core values of Internet
developers almost since its inception and certainly, since, it became available to the
public. Switzerland is home to two of the primary Internet regulatory bodies, the WWW
Consortium and Health On the Net Foundation http://www.hon.ch/ @HON. The W3

42
Consortium sets voluntary but fairly universal technical standards used in HTML,
JavaScript and other development and implementation design tools. @HON, which
organized in 1997, sets standards for health and health related web activity. @HON, has
a strict, enforced code of conduct in seventeen languages, requiring trained and qualified
professionals, support not replacement of traditional care, confidentiality, appropriate
credit to source materials, justifiability of products or services, transparent authorship,
transparent sponsorship, and honesty in advertising and editorial policy. @HON enforces
compliance in several innovative ways. The @HON logo, which is displayed on certified
web sites, is active or live. When a web site visitor mouses-over the @HON logo it
will link to the @HONcode web site. Non-certified web site designers can copy the logo
to their web site but cannot copy the active link. Web users are aggressively encouraged
to report any non-active links for @HON team action. The @HON team uses the active
link to perform random web site checks. To earn the right to use the @HON active link
logo, the web site designer must complete a detailed application and submit to a @HON
team examination of the Web site. The applicant must make changes required to come
into compliance with HONcode (HON 1995). @HON is recommended by such
prestigious American medical organizations as the Mayo Clinic When you visit a health
Web site, look for a logo from the Health on the Net (HON) Foundations. Sites that
display this logo agree to abide by the HON Code of conduct. Some sites may choose
instead to publish a statement explicitly affirming that they are in compliance with the
HON Code of Conduct (Edwards, 2000).
The International Society for Mental Health Internet http://ismho.org/, and
WebPsych Partnership sponsored by ISMHO http://www.ismho.org/webpsvch/ are the

43
major American based mental health Internet research, development and self regulating
organization. Membership and use of the ISMHO logo on a web site is open to any one,
professional, consumer or other, who is interested in the development of mental health
resources on the Internet, for a modest annual membership fee. There is no site
evaluation or monitoring such as @HON uses. The goals of these organizations,
however, are not necessarily congruent with those of the professional organizations. For
example, the goal of the WebPsych Partnership is to ensure a high quality of Members
sites and reduce unnecessary competition and harmful in-fighting. In fairness, it does
seem to be focused on promotion of web sites and accuracy of web sites rather than
interaction with clients or other persons seeking mental health information.
Ainesworths web site, http://www.metanoia.org. was organized in 1995 and
remains one of the primary resources for information about mental health resources,
counselor referral and information. She is a consumer report organization. She
adamantly does not hire therapist or market services. Her listings are free, but the e-
therapist must meet criteria that includes having a web site which she evaluated with
@HON standards, communicating personally with individuals, personalizing help to
these individuals, and communicating with individuals through the Internet. She will not
list any sites where services are not offered by a credentialed professional
psychotherapist.
There is a profusion of sites and listings that do not require professional criteria
for inclusion, but do have some criteria. Mental Health Resource with Leonard Holmes
Ph.D. purports to be your guide to over 700 sites; however, these sites include related
professions such as law and unrelated topics such as aliens. The criteria to list with this

44
site indicated that a web site should not be used to advocate or promote the following:
any illegal activity, activities that support or espouse non consensual and/or extreme
violence or sexual aggressiveness toward another individual or group for any reason,
activities that support or espouse hatred towards another individual or groups based on
any criteria and activities and input from individual that violate our inclusive standards
http ://mentalhealth. about. com While these are laudable criteria, they fall short of
mental health professional practice criteria.
Clinicians Yellow Pages http://mentalhelp.net/mhn/yellowpages/; Whos Who in
Mental Health on the Web http://idealist.com/wwmhw/; Find-a-Therapist; and 1-800-
Therapist; list web site for an annual fee, without evaluation or monitoring, similar to a
listing in the Yellow Pages of a telephone directory.
Basically, a psychotherapist practicing on the Internet must establish all the same
security, authenticity, and grievance procedures as the psychotherapist seeing clients in a
physical office. A physical office has a pleasant, soothing decor, locks on the doors,
security system, secure location and procedures for charts, requests for notes and so forth.
In physical office, a therapist must display, at minimum, the occupational license and the
professional license to demonstrate authenticity and grievance resources. The virtual
office needs an effective web site that is uncluttered, appealing, and easy to navigate.
There must be firewall(s) protecting the therapists computer system, SSL across the
network and easy instructions for client firewalls (locks on the doors). Authority to
practice is demonstrated by posting live logos (i.e. licenses) for security (e g., Verisign)
and credentials (e g., @HON). Live logos are linked to the company and the client can
instantly verify the therapists legitimacy to the extent of each authoritative bodys

45
responsibilities. No one denies that these technologies are cumbersome and may well
cause therapists to think twice about practicing on the Internet or incline some therapists
to practice without adequate safety precautions.
Advantages of Internet Counseling
The perceived advantages of Internet Counseling are its immediacy, availability,
anonymity, and economics (Brown & Walz 2000, Fink 1999, Grohol 1999b, Grohol
2001, King & Moreggi 1998, Patterson 2000, Stubbs 2000). Internet access is
immediate, any day of the week, any time of day, any where in the world. One does not
have to wait for business hours or for an appointment. The Internet users in search of
information, companionship, and advice to get through a sleepless night, pain, or spasms
can readily find help in a chat room, bulletin board or informative web site. The Internet
is available in many remote geographic areas where users do not have access to
therapists. It is available to situationally remote users include home bound care-givers,
the elderly, persons with disabilities, and those who would be at employment or social
risk from seeking counseling. The Internet can be anonymous. Personal information
(age, gender, ethnicity, physical condition) can be disguised. Web counseling is
considerably less expensive than traditional face-to-face counseling. The overhead of
maintaining a web counseling site is much less than that of renting office space,
maintaining a staff, occupational license, furniture and equipment, the myriad of taxes,
and other cost of doing business in the traditional setting. Owners of the PsychOptions
site http://www.psychoptions.com/raters & types of services.htm, for example, lists
the following charges: One question/one problem $25; One e-consultation/first on-going
session $50; On-going session $35; Telephone session $50 for 50 minutes. The one
question, e-consultation and on going sessions are all conducted by email. The

46
PsychOptions site offers a sliding scale If you have extenuating circumstances and/or
are over 65+ and/or on a fixed income then you may contact PsychOptions to request an
adjustment and explain the reason why.
Disadvantages of Internet Counseling
Internet counseling is a double-edged sword. The disadvantages of Internet
counseling can be the same as the advantages immediacy, reliability and validity of
information, security (e g., privacy and confidentiality), anonymity, abandonment,
physical absence, ethics, legality, and security (Grohol 1996, Storm & Moreggi 1998,
Oravec 2000). While a potential client may be assured of a response within 48 hours
while a non-crises office client may have to wait a week or two for a first appointment,
the quality of that first contact may be no more valuable than the first phone calls to a
physical office and responses appropriately provided by trained office staff. The
credentials of the Internet counselor may be as valid as those of the office counselor;
however, it is generally more difficult to verify those credentials as demonstrated above
in the extensive discussion of web security. In a traditional office the client can examine
see the professional license and the business license, both of which are required by law
(at least in Florida) to be prominently displayed. The local Better Business Bureau and
Chamber of Commerce can both be contacted to check the counselors business history
and can offer recourse if problems arise.
As discussed above the web is developing comparable resources in @HON and
Metanioa.com, however they are not well known. Furthermore, in a physical site, the
client has recourse if credit card charges, personal checks and cash payments are
mishandled. Again the Internet offers security but many sites promise security (e.g.,
affordablewellness.com) when in fact they are not secure. Buyer beware is never more

47
true than in the Internet environment. PayPal.com acquired by Amazon.com in July 2002
offers some of the same financial recourse as services continue to evolve in the credit
card industry as e-commerce grows. Unless the URL begins with https (hypertext
transfer protocol secured), the site is not secure. Unless there is a small padlock icon on
the status bar of Internet Explorer or Netscape, the site is not secure. Again, many
consumers, especially in a time of stress or crises precipitating contact with a counselor,
may not be aware of these Internet conventions. To avoid the expense of a secured site,
many small merchants ask that credit card numbers be emailed to the site. Email can be
secure but again, if it is, there is evidence of that security that clients are unlike to know
or consider in a time of distress. Does Internet counseling provide privacy and
confidentiality both in personal information and financial information? It can, but many
sites do not.
There is often legitimate concern in physical counseling rooms about thin walls,
crowded waiting rooms, and non-counseling staff access to chart notes. There are,
however, analogous problems in a cyber counseling room the clients own family or co
workers may have access to the screen as the client talks with the counselor or to the
records in the computer. A spouse seeking a contested divorce, a vindictive co-worker
and other persons with agendas harmful to the client may be able to print off logs of the
sessions, emails, or bulletin board postings. Clients, computer end users, may or may not
be aware of what is recorded in the computer program itself. A client can conscientiously
protect his or her email correspondences, and yet never know that the chat session is
automatically being saved by the computer software. The clients own associates may
have more access to the very information that the client needs to have secure from others.

48
Another disadvantage is face validity on the Internet. A well-designed site may
have powerful face validity that speaks volumes for the competence of the web designer
but say nothing about the credentials and skills of the counselor. With a population
accustomed to visual pleasure from screens television, movie, electronic games, and
computer monitors, the design may allow totally unqualified, perhaps even harmful
counselors to gamer large practices. What you see, may not be what you get.
Anonymity, abandonment, and physical absence are closely related. The client
and the therapist for that matter can disguise his or her identity on the Internet. This
reality needs to be built into Internet counseling theory as the modality evolves beyond
applying traditional modes to the new media. The client could also disguise his or her
identity in person although it is more difficult if payment involves insurance policies or
credit cards. Abandonment is a serious risk on the Internet, while it less likely to occur in
a physical practice setting. Traditional clients may feel abandoned when their treatment
is completed, when they are referred to another mental health care provider when these
issues required different skills or training, or, in a clinic setting where the counselor turn
over may be high; however physical sites rarely just disappear the way web-sites do.
Some argue that no interpersonal bond in the cyberspace can replace actual physical
presences (Plant, 1996).
Cognitive Behavioral Counseling Models
Cybercounseling is not limited to one or a few theories or therapeutic models of
counseling. Researchers have studied family (Oravec 2000), self help (Storm & Moreggi
1998), group (Barak & Wander-Schwartz 1999, Colon 1994, Suler 2000), and brief
cognitive (Edelstein 1996, Palmer & Ellis 1995, Ellis 1996), therapies conducted in
cyberspace. This study, however, will apply the brief cognitive behavior therapy model

49
because it is best suited to the participant population, personal growth issue-focus and
alliance development. As such it provides a model appropriate for 3-session, personal
growth focused study conditions.
Cognitive Behavior Therapy
Cognitive Behavior therapy grew out of the work of social learning theorists
including Lewin, Bandura and Lazarus. Prominent researchers in this important area of
theory and therapy include Ellis, Miechenbaum, Beck, Bums, Marks, and Rush.
Miechenbaum (p. 179-198) describes the process of therapy as involving three mental
constructs he calls cognitive events, cognitive processes, and cognitive structures. His
theory links these cognitive constructs to emotion, behavior and logical and natural
consequences of those behaviors. Cognitive events are conscious, identifiable and readily
retrieved thoughts, images and feelings. They include appraisals, expectations,
attributions, self statements, automatic thought and internal dialogue. The person
experiences them as spontaneous, and rarely questions them. These events occur when an
individual is trouble shooting a problem, uncertain about an action or choice, and when a
routine behavior is blocked requiring an alternative or creative solution. Cognitive
processes are the mental processes by which we acquire information, store it in short
term and long term memory, appraise information, filter it, and recall it. Meichenbaum
identifies three cognitive processes that lead to emotional distress confirmatory bias,
mental heuristics and metacognitions. Confirmatory bias is pre conceived notions or
ideas that function as fact. Mental heuristics in the habit of selecting experiences or
information that confirm pre-conceived biases. Meta cognition is the ability, knowledge
or skills to be aware of and control ones own cognitive processes. The process and goal
of cognitive behavior therapy is to educate the client in recognizing his or her cognitive

50
events, cognitive processes and meta cognition. Cognitive templates or schemas are
identified and the client is enabled to change those templates that no longer function in
his or her best interest. Meichenbaum encourages the client to be his or her own folk
scientist and assigns experiments to develop needed skills. He encourages therapists to
use specific examples to identify faulty logic We have found that people often make
certain kinds of errors in the way they look at situations and that these errors in thinking
may contribute to arriving at premature or incorrect conclusions. Its natural to readily
come to such conclusions without even noticing them (p. 193). Logical errors include
all or nothing thinking, seeing possibilities as certainties, dichotomous thinking,
personalization and self blame for negative events, and over generalization. Because this
theory and therapy relies on homework and experimentation by the client to reach his or
her own conclusion, that affect change, it is adaptive to an Internet Counseling
environment.
Gabriel & Holden (lecture reported in Laszlo 1999) developed an Internet
protocol for cognitive behavioral therapy, that looked at theme patterns in text based
sessions. They sough patterns of over generalization as indicated by the use of polar
adjective, excessive self attribution of responsibility, minimizing or maximizing
significant issues, and focusing on negatives (p. 296-297). There does not appear to be
further information on their theory or research but it is intuitively practical.
Ellis developed Rational Emotive Therapy (REBT) in 1955 and changed the name
of this theory and method to Rational Emotive Behavior Therapy in 1993 to include the
Behavioral component of change, which had always been present in his theory (Ellis
1998). He posited emotional and behavioral problems have their source in faulty

51
thinking or irrational beliefs. His ABC model has grown alphabetically over time but still
focuses on an Activating event, some event at work, home, or interpersonally that triggers
the emotional crises or Consequences. The client experiences the Consequences with or
without being aware to the triggering event and generally without being aware to the
irrational, rigid belief that connects a triggering event to the emotional or behavioral
consequence. In REBT, the irrational Belief is Disputed using cognitive skills introduced
by the therapist but practiced in homework by the client. The outcome is effective and
efficient responses to would be Activating events. Ellis identified eleven irrational
beliefs that cause the gamut of emotional problems.
Some of the websites established by founding CBT therapists are located at:
Aaron Beck, M.D. http://www.beckinstitute.org; David Burns, Ph D. -
http://feelinggood.com ; Albert Ellis, M.D. Http://www.rebt.org ; Isaac Marks, M.D., -
http://www.thisiswiltshire.co.uk/; Donald Meichenbaum Ph D. -
http://www.arts.uwaterloo.ca ; and A. John Rush, M.D.
http://www3.utsouthwestem.edu/psvchiatrv/facbios/rush.htm/
Brief Cognitive Behavior Therapy
Ellis (1996), Beck (1979) Bums and Meichenbaum (2000) have each researched
and developed brief cognitive behavior therapy protocol some of which are as brief as
one session maximum benefit. In a World Counseling Network forum Ellis (1998)
describes REBT as designed originally because psychoanalysis and most other forms of
therapy were very long winded. So I tried to devise a system that would understand the
core beliefs, the core irrational beliefs of the clients very quickly and help them to get to
work to dispute them and debate them in a short period of time. So in a sense REBT was
on to the few therapies designed to be brief (p.2). In reply to a question about efficacy

52
of short term therapy, Ellis mentioned that at least 1000 empirical studies. tend to
show that short term therapy at least when it is done with CT or REBT definitely is as
effective or more effective than other kinds of therapy and more effective than the
therapy that is given to control groups (p. 4) He further cautioned White, de Shazer,
Watzlawick and other brief therapy authors that they had better not use the generic term
brief therapy to imply that they are the only form of brief therapy.
Ellis (Palmer & Ellis 1995) was trained in psychoanalytical therapy but realized
that it takes a fairly long time to get people to free-associate, analyze their dream and go
over and over their childhood and later historical material. He describes his early work
as psychoanalytically oriented as opposed to classic psychoanalysis. I found out, to my
surprise ...that it was better, got better result than classical analysis... you quite quickly
get their basic history (p. 68-69). He continued REBT is intrinsically more efficient
and briefer. Often during the very first session I can show people the ABCs of distress. ..
. So REBT is sometimes successfully done in a few sessions (p. 69).
In his book on brief therapy, Ellis (1996) affirmed that REBT can be
accomplished with self help materials including books and cassettes that teach the REBT
principles Edelstein (1996) advocated three minute REBT sessions applied twice a day
focused on Ellis construct of musty thinking. He demonstrated that one session can be
sufficient to teach the principles of Rational Emotive Behavioral Therapy and involve the
client in three-minute techniques. In the forward to Edelsteins book, Ellis, founder of
REBT, says Of course it takes significantly longer than three minutes to dislodge the
many dysfunctional aspects of a troubled personality. But the clear and simple exercises
advocated by Dr. Edelstein, exercises, which are totally consistent with my principles of

53
Rational Emotive Behavior Therapy, can be practiced in three minute segments, to be
repeated several times a day.
Wood (2001) describes the typical CBT length of treatment as brief. One of the
major features of CBT is the relatively short time frame required for change to begin.
Some brief interventions were developed using the CBT approach for a one-time,
several minute session (suitable for application by generalist health workers such as
nurses and general practitioners). She emphasized that even when these extremely brief
sessions are not used, CBT rarely requires more than 6-12 months, which would include
scheduled follow-ups for gain maintenance and stabilization.
Brief therapy mandates that a therapeutic relationship develop quickly, therefore
numerous researchers emphasis the need to carefully select high functioning clients who
have a high level of interpersonal functioning. Seriously-ill clients should be referred for
long-term therapy where development of the interpersonal relationship can be the focus
and goal of therapy. (Safran & Muran 1998) These authors recommended that early
priorities in brief therapy should be to develop the therapeutic bond with warmth, respect
and genuine interest, reminiscent of Rogers. They offered that the therapeutic rationale,
the goals and tasks needed to accomplish that goal, should be laid out in the first session.
They summarize their recommendations metaphorically as part Marcus Welby and part
Sherlock Holmes.
Using Brief Therapy with Undergraduates
It seems reasonable to assume that most college students are high functioning by
virtue of meeting admission criteria and remaining in an environment that requires self-
care and executive functioning. Those who are not high functioning will quickly come to
the attention of the resident advisors, concerned friends and faculty, or the crisis center

54
and be referred for appropriate care or encouraged to return home for care. This is not to
suggest that college students do not have serious mental health issues and concerns but
rather that they are most likely to have the personal talents and resources to maintain
functioning through personal crises and while seeking counseling services available.
Wilson (1978) addressing common developmental problems of career direction,
sexuality, belief clarification and separation from parents, went so far as to suggest
classroom and resident hall intervention would provide cognitive interventions by
providing problem solving development. Archer and Cooper (1998), Pinkerton and
Rockwell (1994) and Steenbarger (1992) have applied the tenets of brief therapy to the
target population of this study. Although each of these researchers found that there is
resistant on the part of colleagues to endorse brief therapy, their research and the research
of others found brief therapy to be both effective and efficient in campus counseling and
mental health counseling.
Luckey (1996) and Christmas (2000) addressed the use of Internet communication
modalities with college students. Indiana University of Pennsylvania,University Health
Services (Luckey 1996) used the Internet for communication and data base processing.
Because this work was written early in the public access to the Internet, its application
appears to be limited to communicating with and retrieving data from colleagues rather
than direct student services. However, four years later, Duke University (Christmas
2000) was using unsecured E-mail (password protection only) with the student body
population and had established guidelines for interaction with students by email. These
guidelines specify the exclusion of sensitive information that North Carolina state law
requires a health care provider to present to a client in person (e g., positive HIV lab

55
results, pap smear results, workers compensation information, and some prescriptions).
It does not appear that Duke University student health services were providing counseling
services via the Internet; however the guidelines do not seem to exclude such use as long
as topics precluded by state law from remote access were not discussed. It is significant
that Duke University was not using an encrypted site.
Undergraduate Personal Growth Concerns
University administrators, entrusted with the education, safety and well-being of
hundreds of thousands of young adults, many of whom are away from home for the first
time, have needed to know the kinds of stressors, issues, problems and concerns typically
manifested on a college campus. Murphy and Archer (1996) identified thirteen academic
stressors and fifteen personal stressors in a survey of 639 students attending the same
university as participants in this study. Academic stressors confirmed by a significant
number of respondents included tests and finals, grades and competition, professors and
class environment, studying, finances, papers and essays, speaking in class, and others.
Personal stressors confirmed at a significant level were parental conflicts and
expectations, finances, interpersonal conflicts, judgment and acceptance by peers,
personal achievement and goal setting, approaching and meeting other students, general
adjustments to change, personal appearance, current job, and other. The other category
allowed students to include stressors not mentioned in the survey. The most frequent
other was not getting enough sleep, followed by finding time to get everything done.
Other statistically significant stressors were family member illness or injury, personal
health, and pledging. These are the types of issues thought to be appropriate for personal
growth sessions conducted during this study. The study illustrated that while the rank
order of problems changed from 1985 to 1993 changed, the categories remained the

56
same. The same is assumed to be true between 1993 and 2002; however it recognized
that the wide spread access to the Internet, the university requirement of personal student
ownership or ready access to computers, the use of Web based and distant learning and
the events of 9/11/01 may have generated new categories of concern not relevant in 1985
or 1993 although no such new categories were observed in the present study.
Individual Information Processing Differences
Many factors have been demonstrated to influence how individual process
information such as therapy input and tasks results. Some of these include environmental
and cultural variables such a race, gender and ethnicity, brain lateralization with emphasis
on processing information verbally or with images, and personality traits including
introversion and extraversin.
Demographic Factors
The major premise of the huge national investment in Telehealth/Telemedicine is
that technology provides a method to reach under served populations women,
undereducated citizens, rural citizens, Native Americans, citizens with disabilities, and
citizens of color (HCFA 1996, HCFA 1999). The concern of researchers (Reid 1994,
Powell 1998) is that the price of technology, and the education and experience required to
uses these resources may effectively exclude the very populations it is thought to most be
able to benefit. Powell (1998) found that the majority of Internet therapy users were
male.
Learning Style Theory
Learning style, brain lateralization, and information processing research and
theory have contributed a substantial body of information indicating that people encode,
process and retrieve information in distinctly different manners. Two style systems are of

57
interest to the present research, academic oriented learning styles and temperament based
learning styles. Academic learning style theory addresses specific skills and tasks
generally incorporated into formal pedagogy. Temperament based learning styles affect
how the individual learns formally or informally by his or her inborn nature and traits.
Academic Learning Styles
Of the researched styles, verbal, visual, kinesthetic, group, individual, oral
expressive, and written expressive (Babich, Burdine, Albright & Randol 1976), the most
consistently identifiable and validated styles have been visual and verbal (Lazarus 1964,
Richardson 1969, Richardson 1977, Delaney 1978, Dyckman & Cowan 1978, Akins,
Hollandsworth, & O'Connell 1982, Akins, Hollandsworth, & Alcorn 1983, Pavio &
Harshman 1983, Maclnnis & Price 1987).
Richardson (1969) cites a late 19th century researcher, Lay, who illustrated his
concept of the misunderstanding among people as being a result of learned or innate
preference for verbal processing or visual processing with the historical animosity
between Greek philosophers Socrates who heard the voice of his daemon and
Protagoras who thinking and debating relied upon visual/kinesthetic processes.
Richardson quotes Lay as saying if one is auditory-linguistic he should never enter into
an argument with a motor-linguistic person, as on all topics except the most concrete
facts, either will inevitable fail, completely, to understand the other (p. 83). The
preference many mathematics students have for either word problems or equations is a
relatively common example of the encoding, processing and retrieval impact of verbal
processing or visual/symbolic processing, respectively. Lazarus (1964) deemed visual
processing to be a crucial factor in systemic desensitization therapy. Now, nearly 40
years later, the question must be asked if the ability to visualize a virtual counseling

58
environment is an individual difference in the ability to developed a therapeutic working
alliance and produce a satisfactory therapeutic outcome. As potential clients are
evaluated for cyber counseling, should their preference for verbal processing or visual
processing be considered?
Visual Learners
Maclnnis and Price (1987) summarized the role of visualizing in marketing as a
processing mode in which multisensory information is represented in a gestalt form in
working memory. The visualizers were found to use daydreams and fantasy in addition
to graphically and pictorial representations in problem solving. Babich (1976)
operationalizes the visualizing construct as the preference or ability to learn from seeing
words or numbers and remembering spoken information by writing it down.
Richardson (1983) found that the visualized s thinking processes consisted of pictorial or
visual images. The visualizer attended to the spatial layout, physical features, and
sensory input of information to be encoded.
Verbal or Auditory Learners
Babich, Burdine, Albright & Randol(1976) operationalized the verbalizing
construct as a preference for hearing words or numbers spoken and noted the common
practice of verbalizers to vocalize or move the lips or throat while reading written
materials. Richardson (1983) found that verbalizers thinking processes consisted of
spoken words or self-verbalizations, that is, linguistic encoding, labeling or naming. He
likened it to an experience of inner speech.

59
Temperament Learning Styles
A second widely used learning style indicator has been developed by educators
using the MBTI temperaments (rather than types). The learning styles are
SensingPerceiving (SP), SensingJudging (SJ), iNtuitingThinking (NT) and
iNtuitingFeeling (NF). Dean (1997) noted that these four personality were recognized as
early as 450 B.C.E. These four temperaments are found in the sixteen types associated
with the Gallagher (2002) describes people with the SJ temperament as guardians of
tradition or traditionalists, learning from the past. People who prefer to use the SP
functions are artisans and experiencers who learn best from their own work and
experience. People who draw primarily upon the NT functions learn best conceptually
looking for rationale, explanation, theories and hypotheses. People who depend most
strongly on the NF functions are seen as idealists and learn inductively.
Sensing Perceiving
\
Dean (Dean, 1997) proposed that people using the SP function combination or
temperament are similar to those CITE. describes a kinetic tactile, preferring hands on
and active learning situations, which offer the opportunity to construct, operate and
manipulate objects.
Sensing Judging
People using the SJ learn best when their classroom, counseling environment, or
other learning situation provides clear expectations and a right way to do things. Clear
directions, specific extra-therapy assignments and an overtly structured session are
valuable assets to learning for those using the SJ functions

60
Intuitive Thinking
People using the NT style learning well from long-term independent projects,
experimentation, inventions, and complex problem solving. This style is somewhat
similar to the visualizer and group independent style.
Intuitive Feeling
NF users need cooperative personal relationships and leam best in a friendly
atmosphere. They do not do well in rote, non-democratic environments. They prefer
ideal relationships and excellent interpersonal communication skills somewhat similar to
verbal or auditory learners.
Learning Style Conceptualization Comparison
It should be noted that although there are some similarities between the C I T E,
learning styles and the MBTI learning styles, they are not redundant and each offer a
different perspective on learning. Designed for the classroom, the C.I.T.E. learning style
taps actually educational activities preferences in its items and classifications, while the,
based on the broad Jungian theory of personality and temperament, is more generalized
and perhaps more applicable to life long learning in an educational format and well as in
life in general learning. Therefore, both measures were used as independent measures in
this study.
Measuring Information Processing
Richardson (1977) developed the Verbalizer-Visualizer Questionnaire to access
the extent to which ones thinking processes consists of words or self verbalization versus
pictorial or visual images. It consists of 15 forced choice items adapted from Paivios

61
86-item Ways of Thinking Questionnaire. The questionnaire was normed using junior
high school students.
While Richardson examined information processing in social psychology,
education psychologists Babich, Burdine, Albright and Randol (1976), developed a
learning style inventory, which is widely used today. They targeted three areas of
concern information processing, work conditions and expressiveness preference. It is
the information processing visualization, verbalization that parallels the social
psychology work. Items were drawn from the same source material as the Visualizer
Verbalize Questionnaire, has more extant reliability and validity data, is published and
readily available, and has been used extensively in education, adult education, career
counseling and vocational rehabilitation. The Center for Innovative Teaching Experience
Learning Style Inventory (C.I.T.E.) is used by the Veterans Administration and public
school districts across the country to identify learning styles and to guide instructors,
counselors and teachers in designing learning experiences to maximize the students= use
of their preferred learning style. The West Virginia Adult Basic Education program uses
the CITE as its primary assessment instrument to guide recommendations for tutorials,
adult learning experiences, and vocational training.
Myers and Briggs (1962) developed an extensively studied, widely used
assessment tool, the Myers Briggs Type Indicator (MBTI) to measure the individuals
trait preferences consistent with Jungs theory. There are four independent dimensions,
introversion/extroversion; sensing/intuititing; thinking/feeling and judging/perceiving.
Interpretation of the type involves hypotheses about the interactions of these
dimensions and involves understanding of dominant functions, auxiliary, inferior

62
functions, and so forth. The result of an MBTI is one of sixteen types that purport to
describe a persons inherent functioning and are used to help people understand why
others respond differently in the same situation. Keirsey and others have focused on
temperament grouping and developed their own variations on the MBTI; however, the
MBTI was used for this study because it provided both the learning style data and
personality trait data discussed below.
Personality Attitudes
Except for those clinicians who practice radical behavioralism, individual traits
play a prominent role in the planning, conduct, process and outcome of psychotherapy.
Jung (1923) was once of the earliest psychiatrists to postulate personality types. He
identified polar attitudes that he called introversion and extraversin. In the MBTI users
manual, Myers (1962, p. 9) describes extraversin as a trait or attitude of people who
like to focus on the outer world of people and activity. They direct their energy and
attention outward and receive energy from interacting with people and from taking
action. She describes introversion as an attitude of people who like to focus on their
own inner world of ideas and experiences. They direct their energy and attention inward
and receive energy from reflecting on their thoughts, memories, and feelings. Eysenck
(1970) suggested that personality is biologically determined and is arranged in a
hierarchy consisting of types, traits, habitual responses, and specific responses. Eysenck
built upon Jungs theory with empirical research, describing a structure of personality
along three dimensions, one of which was introversion-extroversion. Brinegar (1992),
researching the predictive value of the MBTI in counseling outcome found that
extraversion-introversion dimension surfaced as the only single dimension score to be
significantly correlated with counseling outcome. Myers, as early as 1962, suggested

63
implications for counseling based on type and counseling goal vocational and career,
education and learning, organizational team building and provides guidelines for using
introversion/extraversion (as well as other scales) appropriately in each setting.
Introversion
The trait of introversion is generally associated with a preference for
communicating in writing, working out ideas by reflecting on them, being private and
self contained, and for taking the initiative when a situation or issue is very important to
the person (Myers 1962).
Extraversin
The trait of extraversin is seen in people who are attuned to their surroundings,
communicate verbally, problem solving by talking through issues, and learn by doing or
discussing (Myers 1962).
Measuring Personality Attitudes
While Jung, Briggs, Myers, and McCaully all thought and taught that the
dimensions are dichotomous, several researchers (Mendelson 1965, Girelli & Stake,
1993) examined the scales as continua and suggested that the forced choice format of the
forces the bipolarity artifact, underestimating the true continuum of the dimensions. The
current protocol for scoring the MBTI has keys for calculating the degree of introversion/
extraversin for example rather than regarding them as dichotomous categories. For the
purpose of this study, the scales were treated as discrete traits.
The dimension relevant to this study is Introversion/Extroversion. Livingood
(1995) found that the number of introverts on these (Internet mail lists by MBTI type) is
five times greater than the number of extroverts. However, in the United States at large,

64
introverts are a minority group comprising only 25-30% of the total population, (p. 8).
While intriguing, this may be skewed by the obvious fact that the mailing lists are
presumably drawing from a world population rather than a US population. Livingood
himself writes from Australia. This perception may also reflect the observation that the
people who first had access to the Internet and continue to have predominate access to the
Internet are engineers and scientists who make up that 25%-30% of American introverts
(Myers 1982). The use of the introversion/extroversion scale in this study is significant
because the study population is United States citizens or international students choosing
to study in the United States. The participants were recruited from the College of
Education rather than engineering or science.
Counseling Process and Outcome
During the first half of the 20th century, researchers primarily focused on
understanding the psychological processes that affected the well being of the population.
This research generated the great theories of personality and the applied therapies have
helped people enjoy a better quality of life for three generations. In the second half of the
century, researchers began to examine how the therapies produced the results that were
anecdotally abundant. They examined what factors, conditions and environments that
increased or decreased the efficacy of therapies. Financial accountability in government
health care service has driven research in outcome efficacy and consumer satisfaction for
the past two decades. In the mental health field, this research has taken two primary
directions, efficacy of the counseling process, the helping relationship, (Gaston 1991,
Greenson 1965, Hartley & Strupp 1983, Alexander & Luborsky 1986, Klee, Abeles, &
Muller 1990, Kobotovic & Tracey 1990, Horvath & Symonds 1991, Horvath, Gaston &
Luborsky 1993, Horvath & Luborsky 1993) and efficacy of the over all experience,

65
consumer satisfaction (Becker et al. 2000, Cialo 1982, Eisen, Leff, & Schaefer 1999,
McCullough 1993, Preston 2000, Treadwiell, Soetikno, & Lenert 2000).
Working Alliance
For several decades, researchers have attempted to isolate the therapeutic method
or technique that was most effective. This research had limited results when the broad
concept the interpersonal milieu of therapy, first introduced by Freud as transference
was examined. Clarkson distills from the literature and her diverse theory training,
five relationships between therapist and client, which strongly inform this study.
Although not all these relationships may exist in any given therapeutic relationship, and
may not be recognized by all theoretically orientations, each is potentially available
within computer-mediated therapy as in the face-to-face work, however it was the first,
the working alliance, with which this study is primary concerned. Identified therapeutic
relationships include
The working alliance as the part of client-psychotherapist relationship that
enables the client and therapist to work together even when the patient or client
experiences strong desires to the contrary.
The transferential/countertransferential relationship as the experience of
unconscious wishes and fears transferred on to or into the therapeutic partnership.
The reparative/developmentally-needed relationship as intentional provision by
the psychotherapist of a corrective, reparative, or replenishing relationship or
action where the original experience was deficient, abusive or overprotective.
The person to person relationship as the real relationship or core relationship as
opposed to object relationship.
The transpersonal relationship as the timeless facet of the psychotherapeutic
relationship, which is impossible to describe, but refers to the spiritual dimension
of the healing relationship. (Clarkson, 1995)

66
To measure the presence and relative weight of these constructs research teams at
the University of Pennsylvania developed the Penn Helping Scale (Alexander & Luborsky
1986); at Vanderbilt, the Psychotherapy Process Scale and the Negative Indicators Scale
(Suh, Strupp, & O'Malley 1986); and at Simon Fraser University, the Working Alliance
Inventory. (Horvath & Greenberg 1986). These projects all based their work on the
Bordins (1976) three-factor operational decimation of the helping, therapeutic, working
alliance that consisted of interpersonal bond between the client and therapist. This is
transference/counter transference without a pathological implication. Bordin further
suggested the need for agreement between the client and therapist as to the goal of therapy
and agreement as to the tasks required to accomplish this goal. From 1976, Bordin
maintained that, to be effective, the therapeutic relationship must be collaborative, not
hierarchical.
Measuring Therapy Outcome
Outcome evaluation has evolved from early opinions of the therapists, to complex
testing using instruments including the MMPI (McCullough 1993), to semantic
differential studies designed to cover all possible theories available and obfuscate the
purpose to the measure to avoid contamination (Stiles 1980), to market driven consumer
satisfaction surveys (Patterson & Leach 1987). Therapist opinion may be highly accurate
or may be self serving in any given situation. A structured form of therapist opinion has
been developed and normed over four decades and five versions of the Diagnostic and
Statistical Manual. (DSM). The Global Assessment of Functioning (GAF) (APA 1994) is
the most widely used outcome measure because it is the Axis 5 measure, required as part
of the five-axis mental health diagnostic report. Its use has been increased by the demand
of most HMOs and PPOs for use of the five-axis system.

67
The origin of the GAF is the Health Sickness Rating Scale (HSRS) developed in
1962. It consisted of thirty case studies and seven scales ability to function
autonomously, seriousness of symptoms, degree of discomfort, effect on
environment, utilization of abilities, quality of interpersonal relationships, and
breadth and depth of interest. A single score results as is true for the GAF. These scale
concepts can still be identified in the descriptions of the levels of functioning in the GAF.
The Global Assessment Scale (GAS) was a simplified form of the HSRS and has a .9
correlation with the HSRS. The GAS more closely resembles the GAF, in that it no
longer has scales or case studies. The descriptions illustrate each 10-point range on a
scale from 0 to 100. The GAF was identical to the GAS except it had a range of 0 to 90
in the DSM-III-R, however the scale has been returned to 0-100 in the DSM-IV.
(McCullough 1993). Other recommended instruments to be included in a core battery
are the Beck anxiety and depression inventories, the Hamilton anxiety and depression
rating scales, the psychiatric status schedule, the social adjustment scale, the Health-
Sickness rating scale, the MCMI, the Wisconsin Personality Disorders Inventory and
such. These measures however are more appropriate to a clinical population that allows a
statically significant range of change. Nations such as Australia and New Zealand who
have social health care have conducted extensive outcome scale development and
utilization studies (Eisen et al. 1999, Preston 2000). While these instruments are much
more concise and economical than the battery of tests recommended by McCullough,
they are again more geared to the outcome of clinical populations.
Consumer satisfaction is a business and marketing concept, which seems to have
entered the health care environment with managed health organizations. Employee

68
Assistance Programs (EAP), social work and rehabilitation counseling seem to be on the
leading edge of development of these instruments, however, reliability and validity has
not been rigorously demonstrated. The consumer satisfaction survey is, nonetheless, the
most appropriate outcome measure for this study of undergraduate students presenting
with developmental and growth issues. Attkisson et. al (1982) developed a college
student satisfaction form that was too specific in it items and too long (82 items) to be
used in this study.
An outcome satisfaction questionnaire was developed for this study using the
work Dansky, et al (1996) as a guideline. The items developed were submitted to a
committee of experts (e g., Delphi Method for evaluation and were used by counselors
and students in a pilot study at a local community college. Counselors and students were
asked to respond to each item based on their experience at the counseling center and to
offer content, wording, and face value feedback regarding each item. The resulting
instrument consisted of two forms, one for participants, and one for facilitators. The
participant form had 12 items, seven Likert-like items about satisfaction with the personal
growth sessions outcome, two Likert-like items assessing the participants self perceived
computer competence, and one Likert-like items eliciting the participants predicted
future uses of computer-mediated counseling. Two items were open-ended qualitative
questions requesting the participants opinions about the personal growth sessions. The
computer-mediated aspect was specifically targeted in the qualitative questions to allow
the participant to appraise his or her experience regardless of assignment to conditions of
the experiment. The facilitator version had similar session focused items but did not have
the qualitative items, the computer competence items, or the predicted future use items.

69
This information was collected in personal interviews with the facilitators after they had
completed their all of their sessions with participants.
Application in this Study
The goal of this study is to contribute meaningful research to under-gird and
advise the developing phenomena of Internet counseling. The foundation for good
counseling has been developed over the past century and for good communication over
the past many millennia. The advent of a new venue for communication and the
willingness of mental health professional to move out into this venue should surprise no
one. As counselors boldly go where no one has gone before providing mental health
services in cyberspace, research asks What is known about the new environment? What
needs to be known? What risks can be anticipated? What risks cannot be anticipated?
What known tools can be used as is? What needs to be retooled? What new tools need
to be invented? No one study begin to answers do all that, of course. The purpose of
existing professional literature is to suggest answers or directions to answers for some of
these questions.
It seems clear from the literature that a rich very human culture has developed on
the Internet over the past 30 years, initiated by graduate students at MIT, Stanford and 7
other prominent universities, who were given carte blanc to see what could be done
with the new technology. Government initiates to provide health care to citizens in
geographically remote areas and the commercial emergence of Internet use have paved
the way for cyber-counseling. Cyber counseling appears to lend itself to brief therapy
with non-crisis clients. Several years of cyber counseling practice have created a need
for research to determine the efficacy of cyber counseling and to suggest predictive
criteria for screening potential clients for appropriateness for cyber counseling. Many

70
questions need to be explored. There are several technologies that can be used virtual
reality, web-cam live transmissions, individual written messages (email), public written
messages (bulletin boards), and live written messages (chat rooms). The Internet lends
itself to group interaction, but individual intimacy is also well represented. The scope of
this study was confined to individual therapy in a live (synchronic) written format. The
individual differences the participant brings to the personal growth computer-mediated
sessions were compared to those that they bring to traditional face-to-face sessions.

CHAPTER 3
METHODOLOGY
Statement of Purpose
The purpose of this study is to examine the efficacy of Internet counseling. Chat
room counseling was compared with traditional face-to-face counseling. Similarities and
differences were measures for therapist-participant alliance and for outcome. Four of the
multitude of individual differences, gender, ethnicity, personality, and information
processing, that each participant brings to the therapeutic setting, were measured to
determine is any difference in impact can be discerned in the face-to-face or computer-
mediated condition. This chapter presents the research hypotheses, dependent and
independent variables, sample population, procedures for training the facilitators,
procedures for the implementation of the personal growth sessions, instrumentation,
experimental conditions and assignment to conditions, data collection and statically
analysis.
Hypotheses
The study will test the following null hypotheses:
Hoi: There is no significant difference in the client reported quality of the
working alliance when counseling is delivered face-to-face or computer-
mediated regardless of gender, ethnicity, personality style, learning style.
Ho2: There is no significant difference in outcome efficacy when counseling is
delivered face-to-face or computer-mediated regardless of gender,
ethnicity, personality style, or learning style.
Ho3a: There is no significant relationship between the client reported quality
of the working alliance and gender in CM Counseling.
71

72
Ho3b: There is no significant relationship between in the outcome efficacy
and gender in CM Counseling.
Ho3c: There is no significant relationship between the client reported quality of
the working alliance and gender in F2F counseling.
Ho3d: There is no significant relationship between the outcome efficacy and
gender in F2F Counseling.
Ho4a: There is no significant relationship between the client reported quality
of the working alliance and ethnicity in CM Counseling.
Ho4b: There is no significant relationship between the client reported
outcome satisfaction and ethnicity in CM Counseling.
Ho4c. There is no significant relationship between the client reported quality of
the working alliance and ethnicity in F2F counseling.
Ho4d: There is no significant relationship between the outcome efficacy and
race/ethnicity in F2F Counseling.
Ho5a: There is no significant relationship between the client reported quality
of the working alliance and visualizing learning style in CM Counseling.
Ho5b. There is no significant relationship between the client reported
outcome satisfaction and visualizing learning style CM Counseling.
Ho5c: There is no significant relationship between the client reported quality of
the working alliance and verbalizing learning style in F2F counseling.
Ho5d: There is no significant relationship between the outcome efficacy and
verbalizing learning style in F2F Counseling.
Ho6a: There is no significant relationship between the client reported quality of
the working alliance and introversion in CM Counseling.
Ho6b. There is no significant relationship between the client reported outcome
satisfaction and introversion in CM Counseling.
Ho6c: There is no significant relationship between the client reported quality of
the working alliance and extraversin in F2F counseling.
Ho6d: There is no significant relationship between the outcome efficacy and
extraversin in F2F Counseling.

73
Descriptions of Variables
The research design consists of random assignment of participants to one of two
conditions. The conditions are face-to-face personal growth sessions and computer-
mediated chat room personal growth sessions. Because the participants were randomly
assigned to one of the two conditions, post-test only were used to measure the variables.
RO 3 face-to-face personal growth sessions Posttests
R1 3 computer-mediated personal growth sessions Posttests
The three sessions were conducted to facilitators who will work with an equal
number of participants in each condition, that is, if a facilitator works with a total of 10
participants, he or she will conduct three sessions face-to-face with 5 participants,
individually, and 5 sets of sessions via computer chat room. Ten graduate students
representing a broad population of counselors (1 male, 9 females; 1 African American, 1
Hispanic; 3 licensed mental health counselors, 3 certified rehabilitation counselors; age
range 23 to 56), from counselor education and rehabilitation counseling were hired and
trained to conduct the personal growth sessions. The participants received extra credits in
their counselor education interpersonal skills, substance abuse, or stress management
classes, at the discretion of their instructor. The quality of the working alliance and the
outcome satisfaction were measured to evaluate and compare the counseling experience
in the two conditions. The individual differences that participants bring to the experience
were measured to determine if any and which differences might predict better success
with one condition or the other. For example, do introverted participants do better in one
condition than they do in the other? Do African American participants benefit more from
one condition than they do in the other? Is there any difference in the working alliance
developed by participants with a verbal learning style in one condition versus the other?

74
This could be a valuable contribution to pre-screening criteria for clients who apply for
computer-mediated counseling.
Dependent Variables
There are two sets of dependent variables in this study, the participant perceived
quality of the working alliance during counseling and the participants report of outcome
satisfaction with the personal growth counseling received plus the facilitators opinions on
the same concepts. The working alliance is a process construct thought to describe the
counselor-client relationship as it pertains to providing a helping environment for therapy
to occur. It was measured with the Working Alliance Inventory. The clients outcome
satisfaction is a product construct that taps the results or benefits gained in therapy. It
was measured with Outcome Satisfaction Questionnaire developed for this study and
described above.
Independent Variables
The independent variables race/ethnicity, gender, learning style and
introversion/extroversion were investigated in this study. Ethnicity is an important
variable because while the Internet makes democracy the free exchange of information
and universal individual input more available to many, there is realistic concern that
some are marginalized because of limited access to technological resources and
strategically administered corporate or organization control of resources (Mantovani,
2001, p. 51).
Gender has been suggested as a differential variable in cyberspace. Men have
long dominated math, science and engineering careers. Internet access and savvy have
grown out of training, familiarity and experience with computer technology. Therefore,
there is concern that women have not had the exposure to computer technology to make

75
this form of communication and counseling available to them. There is also concern that
as women are thought to be more relational in their orientation while men are more
analytical, computer-mediated counseling may disadvantage female clients.
Learning styles that favor visual learning, written expressiveness and/or
individual work may be more adaptive to Internet counseling while verbal learning, oral
expressiveness and/or group work may be disadvantaged in a computer-mediated
environment.
Personality type, likewise, may predispose some clients to more comfort and
effectiveness using computer-mediated counseling and disadvantage others. The
personality trait introversion/extroversion was an independent variable to determine if
introversion is predictive of great outcome satisfactions than extroversion.
Population
The population was a southern university undergraduate population and from a
community college in the same locale, with an age median of 20. This population is
thought to be representative of computer users who use computers for social as well as
technical purposes, have grown up in a technological age, and are of the age and social
class most representative of computer users. Undergraduates volunteered for the study
after hearing a presentation in their classroom, completing a contact sheet with
demographic information, and signing an informed consent. They were provided with a
duplicate of the informed consent form and were randomly assigned to personal growth
sessions in either a face-to-face or computer-mediated counseling condition. Participants
were enrolled in stress management, substance abuse, or interpersonal skill classes in the
department of counsel education or in the student development classes at the community
college. Students (N = 123; M = 29; F = 94) were contacted by their facilitator and

76
scheduled for sessions. Upon the completion of three personal growth sessions, the
participant completed the MBTI, the CITE, the WAI (c) and the OSQ (p) in an encrypted
website monitored by a survey technician available in chat room 5 of the site who was
trained to answer any questions about the mechanics of completing the instruments that
arose. The facilitator, who was not the monitor, completed the WAI (t) and the OSQ (f).
Sampling Procedures
Volunteers were recruited from the population of students enrolled in
undergraduate counseling education classes in interpersonal skills and stress
management. Most participants received a small amount (no more than 2% of grade) of
class credit for participation and three sessions of personal growth guidance. Participants
were quasi-randomly assigned to the twelve facilitators and were randomly assigned to
face-to-face or computer-mediated study conditions. Exceptions were made to random
assignment to facilitators if the facilitator knew the participant or if the facilitator and
participant were unable to find a mutually convenient time to meet. The facilitator each
conducted an equal number of face-to-face and computer-mediated sessions. Pre
induction paperwork included an informed consent, assurance that volunteers are at least
18 years of age, and provision of a code for confidential contact, a phone number, and/or
an email address. All volunteers had adequate computer ability so that they could be
randomly assigned to conditions. The university requires these skills of undergraduates
and requires all undergraduates to own or have access to a computer with sufficient
application software to participate in this study. The computer-mediated sessions were
conducted in the university electronic learning gateway system WebCT. Many classes
are offered or supplemented through this system so all students can be expected to learn
how to use it at some point in their undergraduate career. The university has a computer

77
help desk for students who have any difficulty accessing or using the system and
participants were notified of these services.
Midway through the study, the University moved WebCT to an authenticated server
that required identification at log on. However, the university maintained the original
server for studies such as this that require anonymous or coded logon. This did not
negatively affect the study in any way because site appearance remained the same to the
facilitators and because the participants had never seen the other system. When
participants navigated to the WebCT home page, they found this among other studies
listed individually with a link to the older server (e g. Participants in the Groble
dissertation study click here). The one possible confound was that the new server
relieved the lag time problem encountered in the spring term when the old server was
overloaded. Facilitators either did not notice or did not mention any difference. The lag
was inconsistent in the spring depending on the time of day of appointments.. The lag
occurred when the system was experiencing heavy use throughout the university. The
facilitators may have adjusted their scheduling to minimize this problem.
Data Collection Procedures
The principal researcher established a dedicated, password secured web site with
a text-talk (chat room) application for use by facilitators who conducted the personal
growth sessions and data collection. Recruitment was conducted in the source
classrooms during regularly scheduled class with the instructors permission to discuss
the study, explain the participants rights to withdraw without harm, obtained informed
consent and contact information. The principal researcher did not access to the web site
once the study begins and each assistant was instructed how to secure his or her

78
participants sessions. Sessions were downloaded with the permission of the participant
for further research analysis outside the scope of this study.
Nine graduate students and one recent graduate from the Department of
Counselor Education or the Department of Rehabilitation Counseling were trained in the
study protocol, study logistics, cognitive behavior therapy principles, WebCT use,
Internet Resources for clients, and research on the typical personal growth issues of
undergraduates. All trainings were conducted in person by the principal investigator who
prepared the extensive, detailed manual each facilitator received. Additional computer
specific training was provided by the principal investigator and by University personnel
familiar with the WebCT resources. The principal investigator coordinated with the
instructors for the interpersonal communications, substance abuse, student development,
and stress management classes to present the study during class early in the term and
recruit participants. Participants were contacted individually, randomly assigning to one
of the two conditions, scheduled for first session, given any direction needed for finding
the counseling lab or WEBCT chat room. The principal investigator was available via
beeper during any sessions to insure the safety of participant and availability to the
graduate student facilitators. Facilitators received weekly supervision in accordance with
their program requirements (practicum, research, registered intern, and such) and project
design.
The participants presented genuine concerns common to college undergraduates
such as but not limited to adjustment to college life, time management, study habits,
career indecision, roommate relations, and so forth. The facilitator contacted each
participant to set up the first meeting. He or she gave directions for participation. When

79
the participant was assigned to the face-to-face condition, the facilitator ensured that the
participant understood where and when to meet with the facilitator. When the participant
was assigned to the computer-mediated condition, the facilitator provided direction for
the participant to log on to the chat room at the appropriate time and ensured that the
participant understood how to log on to the system and navigate to the chat session space.
The logistic of the experiment, detailed session outlines, record keeping forms, and the
required readings list are located in the facilitators training manual in Appendix B.
Instrumentation
Working Alliance Inventory (Client)
The Working Alliance Inventory Client (WAI c) is a 36 item developed by
Horvath (1984b, 1986) to be used early in the relationships between the 3rd and 5th
session. It was administered at the end of the 3rd session for purposes of this research.
The Working Alliance Inventory targets the client-therapist relationship in a pan-
theoretical approach. (Horvath et al. 1993 p. 255). It was designed to be counseling
theory neutral while operationalizing Bordins description of the three factor working
alliance tasks, goals, and bond (Horvath & Greenberg, 1986). The WAI consists of 36
items, 12 relating to each of the factors of the working alliance. The WAI, client version
has a Hoyts estimate of reliability of .88 for the goal and task subscales, a Hoyts
estimate of reliability of .85 for the bond subscale and a Cronbachs alpha of .93 for the
composite (Horvath & Greenberg, 1986). Items are rated on a Likert-like scale from one
being never to seven being always.
Sample items (Horvath, 1984b)
I find what I am doing in therapy confusing (Tasks)
I am worried about he outcome of these sessions (Goals)
(name of counselor) and I understand each other. (Bond)

80
The advantage of these measure are that they have forms for both the participant
and the therapist providing the opportunity to view the therapeutic relationship through
both lenses. The forms are attractive, well researched and easy to understand and
complete with a minimum of time and effort on the part of the participant. The questions
are non-threatening and non-intrusive while tapping all three aspects of the working
relationship defined by Bordin and fundamental to all therapeutic relationship
instruments examined.
Working Alliance Inventory (Therapist)
The Working Alliance Inventory Form T is the therapist version that assesses the
therapist view of the working alliance across all three components of bond, task
agreement and goal agreement.
Sample items (Horvath, 1984a)
I feel uncomfortable with (bond)
My client and I both feel confident about the usefulness of our current
activity in therapy, (tasks)
and I have a common perception of her/his goals, (goals)
Outcome Satisfaction Questionnaire
An outcome satisfaction questionnaire was developed for this study because
outcome measure reviewed in the literature emphasized medical diagnosis and
symptomatology or were site specific dealing with the mechanics of scheduling
appointments and locating offices. Items for this outcome measure were written by the
principle investigator or adapted from existing instrument where applicable. A
committee of experts reviewed the potential items. A pilot study of the instrument was
conducted at a local community college to gather feedback from students receiving
counseling and from counselors regarding item wording, appropriateness, and face value.
Information from the committee and from the community college study were

81
implemented into the final 12 item form developed for participants and 7 item form
developed for facilitators. The facilitator form did not include qualitative questions
found on the participant form.
Students rated their perception of their computer skills and their likelihood of
seeking Internet counseling should they seek counseling in the future. They answered
open-ended questions about what they least liked about computer-mediated
communication as they had experienced it in this study and were encouraged to offer
suggestions, comments, and ideas about the Internet interaction study. Facilitators were
trained in adequate computer skills, as needed, before beginning their work on this
project and were individually debriefed about the other points in end of study interviews.
Myers Briggs Type Indicator Form M (MBTI)
The MBTI is arguably the most researched and most widely used personality
instrument. The Singer-Loomis Type Deployment Instrument (Singer 1996) and Keirsey
Type Indicator (1984/1996) are similar Jungian theory based instruments but less
researched and less often applied. The Keirsey Type Indicator is readily available on the
Internet, although no longer free. The Singer-Loomis is still considered to be a research
tool, and as such not used in applied setting such as business, counseling, and career
development. The strength of the Singer-Loomis is that it is built upon a dynamic theory
of personality growth and change rather than what has been seen as the rather static
typing of the MBTI. The MBTI, however, was used in this study because the
introversion/extroversion scale has consistently been found to have predictive and
discriminative value. The Keirsey and Singer Loomis blend the four scales while the
MBTI is more consistent with Jungs theory that introversion/extroversion is a attitude,
while thinking/feeling and intuition/ sensing are traits. It is the introversion/extroversion

82
scale of the MBTI that was used in this study. Eysenck developed an
introversion/extroversion scale as part of his three factors biologically based formulation
of personality; however, it is more applicable to a clinical population than the population
of this study.
The MBTI is statistically sound. The phi coefficient for reliability ranges from
.55 to .65 for the introversion/extroversion dimensions; .64 to .53 for the sensing/intuiting
dimension; .43 to .75 for the thinking/feeling dimension and .58 to .84 for the
judging/perceiving dimension. The tetrachoric coefficients are higher, .70 to .81 for I/E;
.82 to 92 for S/N; .66 to .90 for T/F and .76 to .84 for J/P. Reliability is found to
increase with the populations age and intelligence. When the data were converted to
continuous scores the reliability estimates are more consistent at .76 to .82 I/E; .75 to .87
S/N; /69 to .86 T/F and .80 to .84 J/P. (Willis, 1984). Table 11.1 (Myers & McCaulley
1993, pp. 177-206) describes the validity studies correlations between the MBTI and the
Adjective Check List by scales, the California Psychological Inventory by scales, the
Comrey Personality Scales, by scales, the Edwards Personality Preference Survey by
scales, the Emotions Profile Index by scales, the Eysenck Personality Questionnaires by
scales, the Maudsley Personality Inventory by scales, the Jungian Type Survey by scales,
the Minnesota Multiphasic Personality Inventory by validity and clinical scales, the
Omnibus Personality Inventory by scales, the Personality Research Inventory by scales,
the Stein Self Description Questionnaire by scales, the Brown Self Report inventory by
scales, the Sixteen Personality Factor Questionnaire by scales and by second order traits,
the State-Trait Anxiety Inventory by state and trait, the Study of Values by scales, The
Rokeasch Dogmatism Scales, the Opinion, Attitude and Interest Scale by scales, the

83
Kuder Occupational Interest Survey by college major and occupational scales, the
Strong-Campbell Interest Inventory (now known as the Strong Interest Inventory) by
occupational themes, the Kolb Learning Style Inventory by scales, the Science Research
Temperaments Scale, the Watson Glaser Critical Thinking Appraisal, and lesser known
instruments including the Conflict Management, the Harbaugh (W)holistic Scales, the
Internal-External Locus of Control and the Intolerance of Ambiguity. The body of work
establishes the MBTI construct validity, divergent and convergent validity.
Center for Innovating Teaching Experiences Learning Styles Inventory (CITE)
The Center for Innovative Teaching Experience, Murdock Teacher Center,
Wichita Kansas School District developed the Learning Style Inventory most prevalently
used in education today. The CITE Learning Style Instrument is composed of 45 items
that the respondent scores 4, 3, 2, or 1. A score of 4 on an item means that the respondent
feels the statement is most like me while a score of 1 indicates that the statement is
least like me. Results were calculated for nine subscales, visual language, visual
numerical, auditory language, auditory numerical, kinesthetic-tactile, social-individual,
social-group, expressiveness-oral and expressiveness-written (Babich et al., 1976). For
the purposes of this study, the visual numerical and auditory numerical are thought to be
irrelevant to the counseling context but were analyzed in case they tap symbolic
language. Items were scored for each category and significance or major learning style
is determined by a cut score of 33 on any scale. The split-half reliabilities were .6 or
better for eighty-five percent of the constructs.
Sample items (Babich et al., 1976)
I remember things I hear better than I read (Auditory)
I would rather read a story than listen to it read. (Visual)

84
Richardson developed a visualize verbalizer scale; however, it has not been used
outside research and is thought to be less applicable to this study than the visual and
auditory scales of the CITE that has been widely used with adult populations and normed
to the same population as this study. Richardsons scale was normed to a middle school
population and the norming sample was small.
Demographics
Participants were asked to indicate their age, gender, and race or races. It seems
unlikely that the population of convenience have have any significant variance in age or
gender but these questions were asked in case the perception of homogeneousness is
erroneous. The age question was not relevant, however the gender question returned
essential data The ethnic composition of the population of this study was expected to be
diverse and thought have significance in the working alliance and outcome of the face-to-
face or computer-mediated sessions.
Data Analyses Procedures
Data were analyzed using SPSS 11.0. ANOVA procedures were used to analyze
the data because this procedure is sensitive to relationships between the independent
variables, gender, ethnicity, learning style and personality traits and the dependent
measures. Means and standard deviation were computed for all significant main effects
and interactions to evaluate the efficacy of computer-mediated counseling compared to
face-to-face counseling in the process dimension, working alliance and the outcome
dimension efficacy.

CHAPTER 4
DATA ANALYSIS
The purpose of this study was to evaluate the efficacy of brief, cognitive
behavioral therapy provided on the Internet in real time chat room modality. The study
compared two sets of participants. Participants in one set met with the protocol trained
graduate counseling student facilitators face-to-face. Participants in the other set met
with protocol-trained graduate counseling student facilitators via the Internet in a
University of Florida, WebCT, classroom chat room. All participants and all facilitators
completed the dependent variable surveys via the Internet through the WebCT evaluation
utility that provided anonymity for surveys. The chat room was set up so that participants
entered by code rather than by name.
Descriptive Statistics for Dependent Measures
This study used four instruments as dependent variables. Two forms of The
Working Alliance Inventory were used, form c for clients and form t for therapist. The
Working Alliance Inventory provided a total score as well as three sub scores per version.
The student version of the Outcome Satisfaction Questionnaire measure provided three
scores and qualitative responses for future analysis. Common to both the participant
form and facilitator form was the outcome satisfaction scale. In addition, participants
estimated their computer use skill on a Likert-like scale and predicted the likelihood that
they would choose computer-mediated counseling in the future. High scores indicate
positive responses for the WAI while low scores report favorably on the OSQ. That is,
the closer a participants score is to the minimum for outcome satisfaction, predicted
85

86
future use, and computer skill the greater their positive response. The closer a persons
score is on any of the WAI versions or scales is to the maximum, the more positive the
response.
The data was evaluated using analyses of variance (ANOVA), that require that the
independent variable or factor consist of two or more levels and that those levels cover all
possible levels of interest to the researcher (e g., male, female). The levels were
qualitative (e g., face-to-face, computer-mediated personal growth sessions) or
quantitative (e g., MBTI introversion/extraversion). The participant endorsed one and
only one level of each factor. Each independent variable in this study met the criteria.
The critical F value to disprove the Null hypothesis at the .05 confidence level is F (critical
1,123) = 3 .92. The independent factors or variables were condition to which the participant
was randomly assigned, ethnicity, gender, academic learning style, personality attitude,
temperament learning style.
Table 1 depicts the meaningful descriptive statistics for the independent variables
- gender, ethnicity, academic learning style, trait learning style, and attitude and for the
dependent variables working alliance, by scales, outcome satisfaction, predicted future
use, and computer/Internet skill level. The table is organized by experimental conditions,
face-to-face and computer-mediated treatments. Table 2 presents the factors and levels
of each factor used in the analyses of variance.
Participant Dependent Variables Analysis
To evaluate outcome efficacy, participants were asked to evaluate the quality of
their experience in the face-to-face or computer-mediated conditions and their outcome
satisfaction. They were asked to predict if they thought they would be likely to use
computer-mediated counseling in the future. They were asked to describe their comfort

87
and skill level with using a computer and using the Internet. To allow the researcher to
examine the process efficacy of these sessions in the two conditions, participants
answered questions about their total evaluation of the working alliance they co-created
with their facilitator.
Table 1 Descriptive Statistics for Dependent Variables by Conditions
Variables
N
Minimum Maximum
Mean
Std.
Deviation
FACE-TO-FACE CONDITION
WAI Task (client)
59
7
44
32.88
8.748
WAI Bond (client)
59
14
60
46.00
10.609
WAI Goal (client)
59
2
36
25.05
8.330
WAI Total (client)
59
23
140
103.93
24.676
Satisfaction (participant)
59
7
27
12.64
4.877
Computer Skill participant)
59
2
7
4.00
1.218
Predicted future use (participant)
59
0
3
.95
.705
WAI Task (therapist)
58
-4
42
27.74
9.049
WAI Bond (therapist)
58
30
60
49.31
8.217
WAI Goal (therapist)
58
-14
33
18.74
10.597
WAI Total (therapist)
58
17
127
95.79
25.360
Satisfaction (therapist)
58
8
23
15.83
3.738
COMPUTER-MEDIATED CONDITION
WAI Task (client)
64
11
44
31.27
8.016
WAI Bond (client)
63
23
60
45.67
8.160
WAI Goal (client)
63
3
36
24.13
7.722
WAI Total (client)
63
52
137
101.22
21.372
Satisfaction (participant)
63
7
24
13.76
4.294
Computer Skill participant)
63
2
10
4.27
1.096
Predicted future use (participant)
63
0
2
.70
.687
WAI Task (therapist)
63
2
44
28.65
9.172
WAI Bond (therapist)
63
34
60
48.86
7.118
WAI Goal (therapist)
63
-8
36
19.57
10.171
WAI Total (therapist)
63
29
137
96.84
24.022
Satisfaction (therapist)
64
7
25
16.42
4.227
The inventory subscales indicated the strength of the personal relationship (bond),
the mutual creations of tasks, which would lead to accomplishing the goal set for these

88
sessions, and ability to delimit, define and specify a goal. The results of their responses
are discussed in the text below and displayed in tables three through twenty-four below.
Table 2 Independent Variables, Levels of Each Variable and Number of Participants at
Each Level
Factors
Levels
Number of
participants
Conditions
Face-to-face
58
Computer-mediated
64
Gender
Male
29
Female
94
Ethnicity
Caucasian
94
African American
12
Hispanic
17
Academic Learning Styles
Visual learners
30
Verbal learners
93
Introversion/ Extraversin
Extraverts
88
Introverts
35
Temperament Learning Styles
Intuitive Thinking (NT)
18
Intuitive Feeling (NF)
53
Sensing Judging (SJ)
41
Sensing Perceiving (SP)
11
Predicted future use (participant!
Participants were asked to predict the likelihood that they would choose
computer-mediated counseling should they decide to seek out counseling of their own
volition rather than being randomly assigned to a condition as in the present study. Table
3 shows the results of the ANOVA. The main effect, learning style, was significant (F =
4.25, p = .042) but no interactions between face-to-face or computer-mediated counseling
and the independent variables were significant.

89
To further analyze the relationship between academic learning style preference
and predicted use, follow up tests were applied. For this variable, the lower value
indicates preference and the higher the score indicates negative responses.
Table 3 Source Table Dependent Variable participant predicted future use of
computer-mediated counseling
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
7.673
17
.451
.897.580
Intercept
15.869
1
15.869 31.520.000
Condition
.280
1
.280
.556.457
Gender
.319
1
.319
.633.428
Ethnicity
6.576E-02
2
3.288E-02
.065.937
Academic Learning Style
2141
1
2,141
4,253.042
Introversion/Extraversion
8.222E-04
1
8.222E-04
.002.968
Temperament Learning Style
1.139
3
.380
.754.522
Condition by Gender
2.739E-02
1
2.739E-02
.054.816
Condition by Ethnicity
.319
2
.159
.317.729
Condition by Academic Learning Style
.113
1
.113
.224.637
Condition by Introversion/ Extraversin
.606
1
.606
1.204.275
Condition by Temperament Learning Style
.309
3
.103
.205.893
Error
52.360
104
.503
Total
142.000
122
Corrected Total
60.033
121
Table 4 displays the resulting means and standard deviation. Those who use a visual
learning style predicted that they would be more likely to seek computer-mediated
counseling should they need counseling in the future (M = .56 SD = .58), consistent with
the study hypothesis that visualizers would be more likely to seek computer-mediated
counseling than verbal or auditory learners (M = .89, SD = .72).
Table 4. Means and Standard Deviation for Significant Main Effect Academic Learning
Styles; Dependent Variable Predicted Future Computer-Mediated Counseling Use
Academic Learning Style Preference
Mean
Std. Deviation
Visual learners
.56
.583
Verbal learners
.89
.720

90
Level of Computer/Intemet Skill
Academic learning style produced a significant main effect when participants
were asked to describe their level of comfort using computer and the Internet and their
computer and Internet skill level (F = 3.95, p = .049). Table 5 depicts all of the results of
the analysis for this dependent variable. The lower scores indicated greater comfort and
skill while the higher scores indicate less comfort. Participants who endorsed the visual
learning style preference estimated their computer skill to be more limited (M = 4.56, SD
= 1.53) than did participants who endorsed the verbalizer or auditory learning style
preference (M = 4.03, SD = 1.03), contrary to expectation. Verbalizers had better skills
and greater comfort but visualizers predicted greater future use.
Table 5. Source table for dependent variable computer/intemet skill level (participant)
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
28.445
17
1.673
1.297.209
Intercept
532.841
1
532.841412.975.000
Condition
.804
1
.804
.623.432
Gender
2.929
1
2.929
2.270.135
Ethnicity
4.740
2
2.370
1.837.164
Academic Learning Style
5100
§
5.100
3.953.049
Introversion/ Extraversin
5.866E-02
i
5.866E-02
.045.832
Temperament Learning Style
4.434
3
1.478
1.145.334
Condition by Gender
7.398E-02
1
7.398E-02
.057.811
Condition by Ethnicity
.876
2
.438
.340.713
Condition by Academic Learning Style
2.417
1
2.417
1.873.174
Condition by Introversion/ Extraversin
.282
1
.282
.218.641
Condition by Temperament Learning Style
4.021
3
1.340
1.039.379
Error
134.186
104
1.290
Total
2253.000
122
Corrected Total
162.631
121
a R Squared = .175 (Adjusted R Squared = .040)

91
This result is interesting and should be interpreted with caution because it is likely that
the instrument eliciting skills and comfort may need to be enhanced for greater accuracy
(see discussion, chapter 5). .
Table 6. Means and Standard Deviation -Dependent Variable, level of computer/
Internet skill and comfort (participant), Independent Variable, academic learning style.
Academic Learning Style
Mean
Std. Deviation
Visualizer
4.56
1.530
Verbalizer
4.03
1.025
Outcome Satisfaction (Participant)
Participants responses about their outcome satisfaction did not produce any
significant main effect or interaction in the outcome satisfaction measure (Table 7).
Table 7. Source table for dependent variable outcome satisfaction (participant)
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F
Sig.
Corrected Model
356.389
17
20.964
.989
.476
Intercept
5308.807
1
5308.807250.434
.000
Condition
16.177
1
16.177
.763
.384
Gender
25.548
1
25.548
1.205
.275
Ethnicity
84.967
2
42.484
2.004
.140
Academic Learning Style
7.598
1
7.598
.358
.551
Introversion/ Extraversin
9.763
1
9.763
.461
.499
Temperament Learning Style
59.018
3
19.673
.928
.430
Condition by Gender
31.766
1
31.766
1.499
.224
Condition by Ethnicity
29.799
2
14.899
.703
.498
Condition by Academic Learning Style
5.441E-02
1 5.441E-02
.003
.960
Condition by Introversion/ Extraversin
24.616
1
24.616
1.161
.284
Condition by Temperament Learning Style
24.496
3
8.165
.385
.764
Error
2204.636
104
21.198
Total
23887.000
122
Corrected Total
2561.025
121
a R Squared =167 (Adjusted R Squared = .021)
The most positive outcome satisfaction score possible was seven. The score indicating
the greatest possible dissatisfaction with the experience was twenty-eight. The observed

92
score range was from seven to twenty-seven in the face-to-face condition (M =12.64, SD
= 4.88) and from seven to twenty-four in the computer-mediated condition (M = 13.76,
SD = 4.29). This does not mean that the participants were dissatisfied with their
experience but that the measure of satisfaction did not detect any independent variables
that influenced satisfaction. In other words, the participants were equally satisfied in
either experimental condition and regardless of individual differences.
Working Alliance Inventory Total (Client)
The Working Alliance Inventory provided four measures, a total rating, and three
subscale scores. The subscales measured bond, similar to rapport, agreement on goal to
be achieved in counseling, and agreement of task(s) to be developed to accomplish the
agreed upon goal of this episode of brief counseling. There were no significant main
effects or interactions for the dependent variable WAI (c) total score (Table 8).
Table 8. Source table for dependent variable WAI (c) Total score
Sources of Variance
Type HI Sum
of Squares
df
Mean
Square
FSig.
Corrected Model
9574.904
19
503.942
.947.528
Intercept
216085.736
1216085.736
406.031.000
Condition
521.780
1
521.780
.980.324
Gender
153.238
1
153.238
.288.593
Ethnicity
817.424
2
408.712
.768.467
Academic Learning Style
1251.056
2
625.528
1.175.313
Introversion/ Extraversin
109.434
1
109.434
.206.651
Temperament Learning Style
1433.145
3
477.715
.898.445
Condition by Gender
817.339
1
817.339
1.536.218
Condition by Ethnicity
833.397
2
416.698
.783.460
Condition by Academic Learning Style
36.584
2
18.292
.034.966
Condition by Introversion/ Extraversin
206.308
1
206.308
.388.535
Condition by Temperament Learning Style
2112.052
3
704.017
1.323.271
Error
54618.875
104
525.181
Total
1346441.000
122
Corrected Total
63858.369
121
a R Squared = 126 (Adjusted R Squared = -.026)

93
Working Alliance Inventory Bond (Client)
There were no significant main effects or interactions for the dependent variable
working alliance (c) bond,(Table 9).
Working Alliance Inventory Task (Client)
There were no significant main effects for independent variables by WAI (c) task
sub scale (Table 10), however there was a significant interaction between condition and
gender (F= 3.92, p = .05). Unlike the scores on the Outcome Satisfaction Questionnaire,
where lower scores were more positive than higher scores, the Working Alliance
Inventory is scored so that the higher the score the great the positive response. Table 11
shows the means and standard deviation for gender by condition.
Table 9. Source table for dependent variable WAI (c) Bond sub score
Sources of Variance Type III Sum df Mean F Sig.
of Squares Square
Corrected Model
Intercept
Condition
Gender
Ethnicity
Academic Learning Style
Introversion/ Extraversin
Temperament Learning Style
Condition by Gender
Condition by Ethnicity
Condition by Academic Learning Style
Condition by Introversion/ Extraversin
Condition by Temperament Learning Style
Error
1550.132
19
81.586
.914.568
43334.786
1 43334.786485.237.000
2.012E-04
1 2.012E-04
.000.999
9.003
1
9.003
.101.752
312.180
2
156.090
1.748.179
180.325
2
90.162
1.010.368
6.755
1
6.755
.076.784
461.944
3
153.981
1.724.167
7.433
1
7.433
.083 .774
232.154
2
116.077
1.300.277
18.941
2
9.471
.106.899
.261
1
.261
.003 .957
358.995
3
119.665
1.340.266
9109.254
102
89.306
266883.000
122
10659.385
121
Total
Corrected Total
a R Squared = .123 (Adjusted R Squared = -.030)
Male participants reported greater task development congruity (M = 34.14, SD =
8.32) with their facilitator in the face to face than in the computer-mediated sessions (M =

94
27.00, SD =8.63), by almost one standard deviation. This suggests that males were better
able to define tasks needed to achieve their personal growth goals in the face-to-face
condition than in the computer-mediated condition, a finding contrary to expectations.
Female participants seem to develop tasks in collaboration with their facilitator equally
well in either condition. (M = 23.49, SD = 8.93; M = 23.57, DS = 7.43)
Table 10 Source table for dependent variable Working Alliance Inventory (c) Task sub
score
Sources of Variance
Type III Sum
of Squares
df
Mean
Square
F Sig.
Corrected Model
1498.521
19
78.870
1.