Online commentary: marketplace of ideas or shouting match?

A central disruptive technology of our online world is the breaking down of unidirectional communication.  In years past, newspapers and other media published articles without immediate feedback from readers.  True, a few readers might telephone the editor's desk, and the paper might print a select handful of "letters to the editor" in the next issue.  But by and large: "Freedom of the press is guaranteed only to those who own one" (A.J. Liebling, The New Yorker, May 14, 1960).  The average person didn't own a printing press. Now, thanks to blogs, online forums, e-books and the like, anyone can publish.  There is freedom of the press for the masses, but not necessarily an audience.  The ubiquitous comments section in online media thus has a special place in the publishing ecosystem.  Eyeballs are attracted to the professional publication, meanwhile public commentary hangs on its coattails, gaining readership it would not otherwise enjoy.

My local newspaper, the San Francisco Chronicle, has a free online version.  The prolific public commentary is loosely moderated: some comments are deleted for personal attacks, obscenity, and the like.  Nonetheless, an air of bravado, vigilantism, and snap judgment weaves through page after page of commentary.  For example, an unfolding story about a fatal knifing following a baseball game attracts scores of comments with each new revelation.  Readers decide the young men are "thugs," argue over who likely started the fight, declare sports fans crazy and San Francisco as way too soft on crime.  Some proclaim with certainty that self-defense justifies wielding a knife, others just as adamantly that it never does.  There are 145 such comments today, adding to those from yesterday.

Does freedom to express an offhand opinion, and the privilege of having it seen by thousands of others, contribute to public discourse?  On the one hand, a freewheeling marketplace of ideas arguably allows the best to prevail.  Unfettered competition among different ideas, like competing products in a marketplace (or competing species in biological evolution) leads to survival of the fittest.  Neighbors discussing issues of mutual concern over the proverbial backyard fence — isn't this a cornerstone of democracy?

Popular Science takes a different view.  The 141 year old publication this week announced it is ending online comments on its articles.  They say a barrage of commentary that rejects well-established science, e.g., evolution and global climate change, creates controversy where none legitimately exists.  They claim this serves neither science nor the society that depends on it.  The announcement cites a Mother Jones piece that profiles and interviews a climate-change denying "troll"; notably, the 370 comments following that article run the gamut from thoughtful points about climate change to a heated debate about "mens' rights activists" and "femi-nazis" that has nothing to do with the original post.

Meanwhile, back at the San Francisco Chronicle website, a column appeared last week about a young man with apparent psychiatric issues who "is proof that something isn't working with the mental health care system."  He was picked up five times in recent months for bizarre, minor crimes — punching cars, climbing street signs, stripping naked in public, etc.  Each time he was detained on a 72-hour psychiatric hold, after which he was released.  Most recently he was atop a 40 foot ledge for nine hours, screaming and threatening passersby and police, all of which tied up dozens of first-responders, snarled traffic, and cost the city a lot of money.  As a result he is now in the County Jail medical ward, booked on an array of felony and misdemeanor charges.

The 97 comments that follow this column largely decry this man's repeated, rapid release from psychiatric custody.  Here are a few excerpts:

• We need to get the laws in this country changed to make it possible to put people like this in longer-term hospitalization. • Seriously what about some sanity, if your getting picked up repeatedly by the cops you need to be on long term hold. • So basically some lucky person has to be injured or killed by this guy before anything will be done. • Bring back psych hospitals. The pendulum has swung too far to an extreme in allowing the mentally ill to put themselves, and society, at risk on the streets. The social experiment has failed.

A few ideas quickly occurred to me.  We don't apply psychiatric holds based on how much "trouble" people stir up.  He's apparently not holdable — if he were, he would have been held.  Maybe he clears quickly, as would be the case with a medical cause of bizarre behavior, or drug intoxication.  He's detained on criminal charges now, so he won't be released in 72 hours this time unless he posts bail.  But the main thing that occurred to me is how this commentary so glaringly contrasts with that on the psychiatry blogs I read.  In these latter, narrow-focus forums, the predominant tone of the commentary is anti-psychiatric.  No one argues for longer-term hospitalization or says the pendulum has swung too far in favor of patients' rights.

Obviously, this is a matter of readership.  For better or worse, Chronicle readers feel safer with psychiatrists than they do with the man in the news story, and they aren't terribly sensitive about protecting the latter's liberty.  Anti-psychiatrists, in contrast, are a small but vocal minority who disproportionately flock to psychiatry blogs, just as those who reject science flock to the comment boards at Popular Science.  Some of the blogs at Psychology Today also attract devoted critics, some of whom hotly object to the tone with which a sensitive topic has been discussed.  (My blog is apparently not controversial enough to attract such vitriol.)  Should psychiatrist bloggers and those at Psychology Today follow the lead of Popular Science?  Should we disallow commentary, claiming that it creates controversy where none legitimately exists, and that this false controversy serves neither our professional work nor the society that depends on it?

In my view, the answer is captured by a variation of the Yerkes-Dodson law.  That is, too little agreement is just as bad as too much.  An echo chamber of unanimity brings conversation to a halt, as does a cage fight where everything offered is criticized in a hostile way.  Discourse proceeds best when all parties and views are treated with respect, and when a substantial shared basis for discussion exists.  In my opinion, commentary should be permitted on online forums.  However, comments that reject the basic tenets of the discussion — the legitimacy of science in a science forum, mental health treatment in a psychiatry or psychology forum — should be disallowed.  Speakers have a right to express such views, of course, just not by usurping the forums and readership of their opponents.  Likewise, off-topic comments, whether commercial spam, political diatribes, or pet peeves, do not add to thoughtful discourse.  Nor does overt contempt or name-calling.  This means comment moderation is needed, which adds effort and expense to operating an online media outlet.  But the situation as it is now does not serve public discourse very well.  Freedom of speech is not the freedom to grab the microphone from the speaker's hand and use it to shout to a crowd who came to hear someone else.

Online psychotherapy

Telepsychiatry is clinical evaluation and psychiatric treatment at a distance.  It brings a specialist's expertise to otherwise inaccessible populations in prisons, military settings, and distant rural communities.  Introduced decades ago, it is perhaps the most successful example of the more general field of telemedicine.  Telepsychiatry traditionally treats patients at supervised sites and makes use of secure, special-purpose video conferencing equipment.  A number of companies offer technologies and services to facilitate telepsychiatry.  The patients served by telepsychiatry often suffer significant mental illness, such that diagnosis tends to be based on overt signs and symptoms.  Treatment is usually pharmacologic. More recently, mental health blogs and articles have trumpeted the growth of online psychotherapy conducted by private-practice clinicians.  While this falls under the rubric of telepsychiatry, it differs in important respects from traditional applications of this technology.  Online psychotherapy is usually conducted as part of a private practice, without institutional oversight or standardization.  The patient is typically at home or work, not in a supervised setting.  Off-the-shelf consumer technologies such as Skype and FaceTime are often employed, potentially running afoul of HIPAA privacy regulations.  And perhaps most crucially, the patients are higher functioning, with more subtle problems that demand nuanced discussion and finessed interventions.

The idea of conducting psychotherapy at a distance is not new.  Sigmund Freud often corresponded with his patients in ways he hoped would be clinically helpful.  Telephone sessions were pioneered in the 1960s with the advent of suicide hotlines, and have expanded to cover many area of mental health counseling.  (See this 1993 discussion of telephone counseling by an attorney representing the California Association of Marriage and Family Therapists.)  Psychotherapy by telephone remains extremely popular, often serving as a temporary substitute for in-person sessions, for crisis intervention between regular sessions, and to maintain a therapeutic relationship when one party moves out of the area.  Despite the lack of visual cues, studies suggest that telephone psychotherapy and counseling are effective and liked by clients.

Early efforts to use the internet as a medium for psychotherapy seemed to take a step backward with text-only channels such as email or chat.  In contrast to a phone conversation, text chatting hides vocal prosody and other paralinguistic features, obscuring irony, double-meanings, and similar subtleties.  Email shares these shortcomings and is also asynchronous, i.e., the conversation does not occur in real time.  Despite the severe limitations of a text-only exchange, early computer programs sparked the public's imagination that someday the computer itself would conduct psychotherapy, and not simply facilitate communication between two humans.  With the exception of highly structured cognitive and psychoeducational interventions, this has not yet been achieved.

Computer-mediated psychotherapy most commonly takes place online, over video conferencing apps such as Skype and FaceTime.  These tools are readily available for free, and are easy to set up and use.  Controversy exists over whether Skype and FaceTime are "HIPAA compliant," although there is a strong argument that cellphone conversations with patients, not to mention unsecured email, are far more vulnerable to privacy breaches (Skype and FaceTime feeds are encrypted by default, whereas cellphone calls and email are not).

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious.  Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or highly contagious with an infectious disease.  Additionally, online therapy reasonably substitutes for telephone therapy in typical situations such as crisis intervention or when an existing therapy dyad is geographically separated, perhaps temporarily.

It is more potentially problematic to choose online therapy over in-person treatment when both are practical options.  Certain patients, e.g., depressed or agoraphobic, may opt not to venture out of the house when it would be beneficial for them to do so.  In-person treatment is inherently a social interaction, which may be therapeutic in itself — or at least good practice.  Psychotherapy at a distance precludes smelling alcohol on the patient's breath, as well as noticing auditory and visual subtleties such as a quiet sigh or dilated pupils.  Micro-momentary facial expressions, implicated in unconscious interpersonal communication, may be overlooked.  And to underscore the obvious, the therapeutic frame may be harder to maintain when the patient is in swimwear by the pool, and drinking an alcoholic beverage during the session.  The potential for patient acting-out, including with suicidal threats or gestures, can render an online therapist especially helpless, and possibly more easily manipulated, than his or her counterpart in an office setting.

Online psychotherapy has practical advantages in some situations, and as a treatment modality it does not appear bogus or inherently harmful.  It would be interesting to compare telephone and video therapy in a research context, to see whether the visual channel confers additional useful information, and whether it enhances or detracts from the therapeutic alliance.  As with most technological innovations, online therapy also introduces new pitfalls and deepens old ones, so it is best not to choose it merely for its novelty or expedience.  Face to face treatment is still the gold standard.

Online anonymity and transference

I've been online quite a few years now.  Actually, I first used the internet in college in the late 1970s.  There were only a handful of non-governmental university sites back then, and I happened to be an undergraduate at one of them.  A decade later, in the late 1980s, I was a member of the first online community, called The Well.  In the years that followed, I was active in online forums about psychiatry and other topics.

By the early 1990s, after my psychiatry residency and research fellowship, I had begun to think about the psychological dynamics of online communication.  Now that it's almost 2009, many dissertations and books have been written on the subject, online communities are commonplace (e.g., see here, here, and here), and most everyone is at least somewhat familiar with online communication.  But nearly 20 years ago it still felt new and ill-defined, and an idea dawned on me that seemed to explain a lot about what I saw happening online.

In the 1980s, the main place for freewheeling discussion online was Usenet, a huge collection of topic-based forums (newsgroups) covering every imaginable subject.  From highly technical discussions of computer technology to frivolous chatter about celebrities, this text-only, worldwide, generally anonymous medium served as a massive reservoir of information and "computer culture."  In addition, local "bulletin board systems" (BBSs) provided similar forums on a much smaller scale, and individual email discussion lists arose where subscribers could read and post commentary outside of Usenet.  In all of these, emoticons (e.g., smiley faces), in-group jokes, and acronyms (like LOL for "laugh out loud") were popularized, and have left their mark ever since.

What most caught my attention, though, were the extremes of emotion expressed.  I was struck by the incredible hostility many users directed toward others.  Snide putdowns, withering sarcasm, and utter contempt were fair game and surprisingly common.  This was collectively called "flaming," as in blasting someone with flames.  Flaming was social behavior that would never be tolerated FTF, IRL (face-to-face, in real life).

My first thought about flaming was that it existed because flamers could get away with it.  They were untraceable due to anonymity and unreachable due to lack of physical proximity.  There were typically no consequences for flaming other than flames directed back in response.  But this failed to account for the hostility in the first place.  Are young men (the demographic of most internet users back then) naturally inclined to such levels of raw aggression anytime they can get away with it?  Not entirely implausible, but a sad conclusion if true.

Then I noticed the opposite as well.  Organized online dating would not catch on until the advent of the World Wide Web and commercial websites in the 1990s, but cyber-romance was already well-known in 1980s computer culture.  People who scarcely knew each other -- and only through text, no pictures -- would flirt eagerly online.  There was an idealization of the unseen other, a belief or hope that he/she was everything one dreamed of.  Of course, stories were rampant of disappointing (or horrifying) results when a meeting finally took place FTF.  But these romances struck me as the other side of the flaming coin.   Hmm, idealization and devaluation -- where had I heard of those before?

Transference was a concept invented by Sigmund Freud to apply to the psychoanalytic situation.  The analysand (patient in analysis) experiences feelings toward the analyst that are "transferred" from parents or other important figures in the analysand's life.  These feelings are often erotic if positive, harshly rageful if negative, and often a mixture of both.  Successfully analyzing the transference is a main task of psychoanalysis, and thought to be central to its curative effects.  For this reason, transference is promoted in psychoanalysis.  By sitting outside the analysand's field of view, refraining from personal disclosure, and maintaining "therapeutic neutrality," the analyst provides space for the patient to ascribe facts and feelings to the analyst and to react to them.  These facts and feelings are created in the patient's imagination, and are not realities about the analyst.  However, the patient's emotional reactions are real, and shed light on long buried feelings and emotional assumptions about others.

I realized that online anonymity, and online communication more generally, unwittingly encouraged transference.  During the 1980s era of text-only discussions on the internet, users literally sat outside each others' field of view and provided little personal disclosure.  (This formed the basis of a now famous 1993 cartoon in The New Yorker.)  Facts and feelings were ascribed to the unseen others online.  These presumed facts and feelings in turn prompted primitive erotic and aggressive feelings, and these in turn led to cyber-romance or flaming.  The main difference from psychoanalysis was the lack of a professional to interpret and contain the transference.  Thus, there was nothing healing or curative about it; it was bad-tasting medicine with no benefit.

Transference helps to explain important aspects of online dynamics in the 1980s.  But much has changed since then.  The graphical user interface of the World Wide Web began to erode user anonymity by the mid-1990s, as home pages with photographs and personal information were uploaded by the millions.  This trend has accelerated with Web 2.0 and current social networking sites like MySpace, Facebook, Twitter, and many others.  Anonymity now seems to be the last thing on the minds of internet users.  Personal details and the minutia of everyday life are routinely shared online.  Job-seekers google potential employers and vice versa.  Potential romantic partners google one another.  In theory this discourages transference; my own unscientific impression is that flaming has become passe, cyber-romance more cynical than idealistic.  I now wonder if we need not fear unwitting transference so much as its opposite: an undue familiarity that makes romantic love and admiration of heros less possible.