REFLECTIONS ON THE CONSTRUCTION OF A QUALITATIVE RESEARCH IN ONLINE PSYCHOTHERAPY¹

ABSTRACT

Internet-mediated services offer a variety form of connection and interactivity, from this, new mental health interventions emerge, requiring research to validate and evaluate such practices. However, studies in the area are scarce, especially guidelines that assist in conducting research involving Internet-based interventions. The purpose of this study was to indicate guidelines for the design of psychological intervention research mediated by the Internet, based on the construction of an interventional research in online, qualitative, descriptive and longitudinal psychotherapy. Six significant aspects for digital intervention. Six significant aspects for research in digital intervention are addressed, including contact with collaborators, criteria for participation, scope of research, monitoring and evaluation of interventions, technological criteria and ethical aspects in the digital field. Technical, qualitative and care aspects necessary to maintain the quality of care and research mediated by digital technologies are raised. It is urgent for Psychology to consolidate a field of knowledge that deals with the influence of technologies on subjectivities, as well as to design studies that scientifically assess the use of the internet for treatment and care in mental health.

Keywords:
Telepsychotherapy; clinical psychology; psychology and computer sciences

RESUMO.

Os serviços mediados pela internet oferecem uma diversidade de formas de conexão e interatividade e, em decorrência, surgem novas intervenções em saúde mental, exigindo pesquisas que fundamentem e avaliem tais práticas. Entretanto, os estudos na área são escassos, especialmente diretrizes que auxiliem na condução de pesquisas que envolvam as intervenções baseadas na internet. Nesse sentido, o objetivo deste artigo é indicar orientações para o desenho de pesquisas de intervenção psicológica na internet, tendo como ilustração a construção de uma pesquisa interventiva em psicoterapia on-line, qualitativa, descritiva e longitudinal. São abordados seis aspectos significativos para pesquisas em intervenção digital, incluindo contato com colaboradores, critérios de participação, alcances da pesquisa, monitoramento e avaliação das intervenções, critérios tecnológicos e aspectos éticos no campo digital. São levantados aspectos técnicos, qualitativos e de cuidados necessários para manter a qualidade dos atendimentos e das pesquisas mediadas pelas tecnologias digitais. É urgente à psicologia consolidar um campo de saber que se ocupe tanto das influências das tecnologias nas subjetividades, também, delinear estudos que avaliem com rigor científico o uso da internet para o tratamento e cuidado em saúde mental.

Palavras-chave:
Telepsicologia; psicologia clínica; psicologia e informática

RESUMEN.

Los servicios mediados por Internet ofrecen una diversidad de formas de conexión e interactividad y, como resultado, surgen nuevas intervenciones en salud mental, que requieren investigaciones que corroboren y evalúen dichas prácticas. Sin embargo, los estudios en el área son escasos, especialmente las directrices que ayudan a realizar investigaciones que involucran intervenciones basadas en Internet. En este sentido, el objetivo de este artículo es indicar directrices para el diseño de investigación de intervención psicológica en Internet, teniendo como ilustración la construcción de una investigación intervencionista en psicoterapia online, cualitativa, descriptiva y longitudinal. Se abordan seis aspectos significativos para la investigación en intervención digital, incluyendo el contacto con colaboradores, los criterios de participación, el alcance de la investigación, el seguimiento y evaluación de las intervenciones, los criterios tecnológicos y los aspectos éticos en el campo digital. Se plantean aspectos técnicos, cualitativos y asistenciales necesarios para mantener la calidad asistencial y la investigación mediada por las tecnologías digitales. Es urgente que la Psicología consolide un campo de conocimiento que se ocupe tanto de las influencias de las tecnologías en las subjetividades como de esbozar estudios que evalúen con rigor científico el uso de Internet para el tratamiento y cuidado en salud mental.

Palabras clave:
Telepsicologia; psicologia clinica; psicología e informática

Introduction

Telecommunication technologies are understood as the use of digital phones, interactions via video call, email, chat, text messages sent by conversation applications, Internet (websites, blogs, social media). The transmission of information may be in writing, may or may not include images, sounds or other data, may be synchronous with multiple parts of real-time or asynchronous communication, with information storage and communication with response time. The interaction can happen between people or self-guided services, having the combination of several technologies, serving different purposes (American Psychological Association [APA], 2013).

Digital technologies also promote the development of new instruments in mental health care, such as e-Health, e-therapy, virtual reality, artificial intelligence, virtual therapists, gamification, development of health monitoring applications for mobile devices. Interventions can bring innovation, whether through virtual reality simulators, using real-time computer graphics, body tracking through sensory input devices, online computerized tests with greater diagnostic sensitivity and specificity, among others. There is a lack of studies that allow a better understanding of the mechanisms of change, greater training in the use of virtual therapies and how to adjust them to the daily routine of treatments, as well as an understanding of their use in the most diverse age groups (Holmes, 2018).

In Brazil, mediations of digital technologies in psychology are still poorly studied and there are few longitudinal studies focused on the psychotherapeutic process (Leitão, 2003; Rodrigues & Tavares, 2016). There is a lack of investments in Psychology programs and the elaboration of resolutions that guide psychotherapists in the use of ICT (Information and Communication technology) (Hallberg & Lisboa, 2016). Other challenges refer to the importance of developing specific training for the new modalities of care (Barak, Liat, Meyran, & Na’ama, 2008) and the appropriate professional management of technologies (Nicolaci-da-Costa, Romao-Dias, & Di Luccio, 2009).

Allowed in a research context since 2000, the CFP published Resolution 11/2018, which authorizes psychological care and other services mediated by digital media. However, few national studies have been developed (Leitão, 2003; Hallberg & Lisboa, 2016). According to the CFP, each technology used must be coherent and grounded in science, legislation and the ethical parameters of the profession. The service, therefore, cannot occur in any way, and it is up to the professional to validate, including in the records of the provision of the service, whether the technology used is technically adequate, methodologically relevant and ethically supported (Conselho Federal de Psicologia [CFP], 2018a). However, the resolution does not point out details about what would be the necessary technological adjustments, in terms of better techniques, methodologies and ethical support, being distant from international initiatives such as the American Psychological Association, American Counseling Association, International Society for Mental Health Online, which guide and monitor the insertion of technologies in online psychological services, encourage their employees to follow behaviors that generally cover the presentation of a consent form, confidentiality, registration of information, specification of the types of technologies.

Online interventions in psychology have increased significantly, which directly reflects the need for research in the area. With regard to studies evaluating interventions mediated by the Internet, there is a plurality of perspectives, approaches are heterogeneous, there are methodological difficulties such as terminology and definitions, selection of bases, research designs, few studies establish guidelines, standards are insufficient and the dissemination of knowledge derived from interventions on the web is not encouraged (Proudfoot et al., 2011; Whitehead & Proudfoot, 2010).

For a scientific foundation of psychological services on the web, it is necessary to expand the dialogue with other areas of knowledge, encouraging multidisciplinarity, signaling care prior to methodological and practical issues of research in Psychology. According to the APA (2013) and the Conselho Federal de Psicologia [CPF] (2018c), it is up to the psychologist to know and evaluate the benefits and limitations of the use of technologies in the particularity of each service and in the use of each device, being essential to monitor the development of area. For a consistent practice, research and systematization are necessary, which indicates the need for reflections that provide subsidies for research on interventions on the web, considering its interdisciplinary character, also oriented from knowledge that dialogues with exact, human and biological areas.

Method

The objective of this study was to propose guidelines for the design of psychological intervention research mediated by the Internet, based on a longitudinal, qualitative, interventional study in online psychological treatment. This objective also includes reflections for psychotherapy processes mediated by the Internet, as it raises issues about aspects of the online environment, necessary for both research and clinical practice.

Regarding the structuring of research on online psychological interventions, initially, a literature review of publications between the years 2009 and 2019 was carried out, in January 2019, in the BVS-Psi, Scielo, Scopus, PsycINFO databases, with the descriptors ‘Internet interventions research’; ‘guidelines’. Two articles were found that specifically deal with guidelines regarding research and scientific communications in health interventions mediated by the Internet (Chee, Lee, Chee, & Im, 2014; Proudfoot et al., 2011). Qualitative longitudinal studies lasting more than three months and dealing with the specifics and nuances of online psychological interventions were not found in these same databases, using the descriptor ‘psychotherapy online’ until January 2019, which signals the need for studies that assess or monitor, register and disseminate, even if following specific theoretical parameters of each approach, the repercussions of technological mediation on psychological interventions.

Research presentation

The postdoctoral level study approved by the Ethics Committee process CAAE 01457118.4.0000.5561 aimed to understand the experiences of technological mediation in online psychotherapy processes. This was a longitudinal, qualitative, descriptive-phenomenological research. In the first stage of the project, six months were dedicated to building the online environment for research, with the study of international legislation that protects psychological interventions in digital media, as well as the rights and duties of psychologists and people who seek digital services. The theoretical foundation of the study is the phenomenology of Edmund Husserl and, also, tangential phenomenological references that dialogue on aspects arising from the theme of the online field. It is a comprehensive philosophical line that, according to Trilles-Calvo (2019), more than a theoretical corpus, proposes an understanding that leads to certain non-isolated steps to achieve a specific end, although not necessarily assumed previously. Its intention is not to analyze, but to provide a rigorous description of what was found. Based on reflections on the construction of a research environment for online psychological interventions, we intend to discuss and point out guidelines for research and scientific communications in the field of telepsychology.

Research on Internet-based psychological intervention- online environment

Surveys on Internet-mediated interventions (Proudfoot et al., 2011) cover a variety of modalities. These may be delineated from demographic factors, symptoms or health issues, psychological indices (such as treatment history, learning styles, locus of control), therapeutic factors, or may be related to technological aspects (e.g., previous experience with computers, etc.), which makes specification of the target population essential. It is important to clearly define and detail how access to the intervention will be, synchronous or asynchronous, whether there are modes of exclusion and specificities of inclusion. It is relevant to consider the emergency mental health support and evaluate the management in cases of withdrawal from participation, considering the remote application of the intervention. In addition, consider how the treatment will be evaluated or monitored and the degree of achievement of the objective of the study, as well as the adequacy and feasibility of the resources used, including the specific characteristics, measures, when applied, schedule of evaluations or follow-up, adherence of participants.

In the case of online psychological care, a careful choice of specific settings for the care environment is suggested. In this sense, it is important that the studies make reference to: types of intervention and frequency; ethical considerations for the remote environment; types of professional support in the area studied and/or support from other areas; interactivity of the developed program; multimedia channels used for the study.

The Ordem dos Psicólogos de Portugal (2016) delimited thirty-five guidelines for research in remote interventions; Chee et al. (2014) propose seven steps for the development of web-based interventions in nursing, (1) meaning and effectiveness, (2) target population, (3) theory of theoretical basis/program, (4) focus and objectives, (5) components, (6) technological aspects and (7) logistics for users; Proudfoot et al. (2011) listed 12 aspects relevant to Internet-based interventions and communications. Due to the scope of possibilities of research on the Internet, six topics related to the structuring of the online environment were delimited for the present study, synthesized from the cited studies (OPP, 2016; Chee et al., 2014; Proudfoot et al., 2011), namely:

1. ) initial contact with the collaborators of the online study

2. ) criteria for exclusion and inclusion in the online survey

3. ) range of online research

4. ) ways of tracking, monitoring or evaluating the online survey

5. ) technological criteria for the development of the intervention on the internet

6. ) ethical aspects of online intervention

It is about illustrating the research design in online intervention, which requires specific procedures, being relevant to protect the emotionally vulnerable person who seeks a service still in a situation of experimentation. In order to prepare the research environment in online psychotherapy, an interdisciplinary dialogue was essential, in particular, the exchange of information between the areas of Law, Information Technology and Psychology, in order to meet the guidelines of the Code of Ethics for Psychologists, the legislation on the use of technologies, according to the CFP Resolution of May 2018, “Considering the provisions of Law 12965/14, which establishes principles, guarantees, rights and duties for the use of the internet in Brazil or legislation that may replace it” (CFP, 2018a, p. 1), as well as the specifics and possibilities of information technologies for structuring this environment, in order to ensure the security of information stored on the website, survey data and restricted access to platform users.

(a) initial contact with the collaborators

The target audience chosen was restricted and limited to nine collaborators: three psychotherapists residing in the city of the research, and six people undergoing psychotherapy, including three participants of exclusively online processes, residing in the national territory and three initiated in loco and interspersed with two online sessions, every four meetings, residing in the research city. Six psychotherapy processes were followed, with weekly sessions lasting one hour, with a minimum duration of six months.

Participants were contacted through the researcher’s online social network groups or by sending an institutional email to psychologist researchers, aiming for a limited coverage, given the limited number of vacancies. In this phase, conversations took place with undergraduate and graduate students, professors and researchers from the university, with attentive listening to reports and perceptions about the practice and mediation of online technologies in psychotherapy, representing the first contact with the theme, recorded in a field diary. This step was fundamental for the selection of collaborating psychologists.

After this initial phase, open face-to-face interviews were carried out with psychologists interested in collaborating with the study, recorded in a field diary. After the selection of psychotherapist collaborators, a reflection group lasting two hours for five months was organized, whose theme was how to structure the design of data collection of research on online psychotherapy. Collaborating psychotherapists, undergraduate students and the responsible researcher participated in the study group.

Access to people who sought online psychotherapy occurred through the disclosure of vacancies on the web, on the same (restricted) social networks of the researcher, for a week until reaching the number of fifteen participants, when the forms were withdrawn from the internet. Interested parties filled out an online questionnaire, with personal data, mental health history, need for emergency care, familiarity with the use of technologies, reasons for online psychotherapy, reason for therapeutic consultation and a final question about the degree of interest in participate in an online process (on a scale of 0-3, in which 0 is none, 1 is little, 2 is face-to-face mediated by technologies, 3 is high), aiming at confirming the interest mentioned in the questions.

An online interview was held with each of the interested parties, explaining how the psychotherapy process would be, duration, research time, treatment of the contents covered in therapy, the guarantee of secrecy and privacy. Information about the differences between psychotherapy and the research context was given, in which specific steps and execution of specific activities would be necessary. In addition, those interested were also informed about the risks of the internet, such as security conditions, delays in message returns, connection drops or network instability, third-party contact for emergency calls, peculiarities of research based on interventions in the internet, in particular, synchronous, in which the unforeseen events of the internet directly affect the participants. Special attention was given to the person’s understanding of the prerequisites, the conditions of mediation of technologies and whether they would be in agreement and clarified about the agreed points.

(b) inclusion and exclusion criteria for the online survey

For psychologists, the inclusion criteria were high interest and motivation for online care, experience in psychotherapy, registration in e-psi (CFP, 2018c). The motivation and involvement with the subject of online psychotherapy, the availability for consultations within the determined time of the study (six months) and the interest in systematizing data for research and scientific dissemination were also evaluated. To be assisted in psychotherapy processes, the participants should have a high degree of interest and motivation to attend via the web, evaluated by the online registration questionnaire and by the online contact with the researcher, have a private environment for the sessions, be over 18 years old and Portuguese as their mother tongue.

As exclusion criteria, reference was made to the CFP Regulation of 2018 and international studies suggesting attention to the use of online tools for some audiences: people diagnosed with schizophrenia, dissociative disorders and other serious mental disorders; chemical dependents and/or alcoholics in abstinence from substance use; people with suicidal ideation (Egede et al., 2009), not being in a situation of violence or in need of emergency care (CFP, 2018a), in the case of using psychotropic drugs, being in psychiatric care.

Specifically for the quality of online service, criteria were also defined with regard to technologies: familiarity with the use of digital media, access to the private internet with a download and upload speed of at least 5 Mbps, to support video calls, own devices under 5 years of use, installation of an appropriate application for the research with evaluation and indication of an information technology specialist, evaluated in the online interview with the researcher.

(c) Research scope

This topic refers to the accessibility of the Internet, as an online survey can have a restricted reach, to a few people or a closed group, or a broad reach, such as interventions open to all audiences and of different nationalities (Proudfoot et al., 2011).

This is a study with a restricted national scope (9 collaborators), with follow-up and in-depth qualitative, descriptive and comprehensive longitudinal analysis of technology-mediated psychotherapy. The restricted scope makes it possible to give visibility to nuances of the therapeutic relationship, the bonds and the relational dynamics involved in each pair, as well as the complications, analyzed in an amplified way, in order to trace directions for a more consistent and ethical practice. It favors the apprehension of subjective details of the intervention, but requires specificities regarding the population and the type of intervention: synchronous or asynchronous contacts (interventions via message or via video call) require differentiated guidance and care in the provision of these resources, since they are different forms of communication that can mobilize each subjectivity involved in a unique way; the protection of the person in psychic vulnerability in the online environment must be evaluated in each session, considering the characteristics of the place where the patient is; it is recommended, when possible, the delimitation of the scope to different populations, as for example, studies with people with specific psychic disorders should be observed in their relativities; finally, other territorial therapeutic resources should be made available in case of complications during the intervention. The explanation of these factors can favor the insertion of the participant in the online environment and can have repercussions on adherence to treatment and research and on the ethical care of the research-intervention.

(d) evaluation and/or follow-up of the online intervention

It is important to consider the inclusion of evaluation and monitoring steps during the process, and not just after the completion of data collection, since the effectiveness of treatment and the success of the project depend on the use of available resources and, above all, on ethical care with those involved. Attention should be paid to possible psychic variations resulting from online contact and also to the person’s well-being, above any research parameter or clinical practice. Continuous assessment and descriptive analysis of weekly care experiences can reveal practical aspects arising from the interface between psychology and technologies, providing reflections on the needs for an adequate online environment, on the specific issues of online clinical management, on the development of the bond and the therapeutic relationship, in order to invest in the minimum conditions necessary for a safe service from a technological and psychological point of view. To this end, the conduct and professional attitude towards interventions mediated by the internet should also be discussed and the need for technological training of both psychologists and people who will benefit from the intervention must be discussed.

Since the beginning of the study, the researcher made a field diary with notes about her own experiences regarding the phenomenon of mediation of technologies in psychotherapy, based on the philosophy of phenomenology, in which an investigation comes from an intersubjective process of apprehension of phenomena and legitimizes the researcher’s subjectivity as a primordial tool, as long as they are in line with reductions leading to the rigor of the phenomenological apprehension. In addition to the diary, a self-administered, individual and online semi-structured script was prepared, with the aim of understanding the nuances of the psychotherapy process, in order to describe the experience of psychotherapy and the use of digital tools. It was composed of identical questions for both therapists and people served. The participants answered after each session about the experience of the psychotherapeutic encounter, environment, use of digital tools. In addition to these, the HTP (House Tree Person) was applied at the beginning and end of the processes and free drawings were made every four sessions.

(e) Technological criteria for internet intervention research

Technological mediations in online interventions must consider the necessary precautions for the use of the Internet and its specific conditions of security, privacy, secrecy, application terms, types of interaction and types of devices. They must specify how to protect the privacy of information exchanged between devices, whether synchronous, video calls, or asynchronous, in cases of message exchanges outside of session hours, whether they will be stored on personal devices or deleted after reading. In order to guarantee confidentiality and ethical protection of the service, the following must be considered: the storage location of the material produced online, the way in which such information is transmitted on the Internet, the privacy conditions of the applications, the devices and the places of service, responsibility and awareness/information about third-party access to asynchronous content, response conditions and interaction between the psychologist and the person assisted.

Both monitoring and reporting on technological support are essential. In the case of this research, an institutional website was created with a restricted access area for study collaborators, psychologists and people served by the program, with individual login and password with multi factor authentication and differentiated access profiles. The website was also a way of accessing and publicizing vacancies for appointments. In this restricted area, all information was encrypted, with weekly backups, where all documents were stored on a specific server for research, aiming at protecting data transmitted on the internet.

Chat applications were selected in accordance with psychology and information technology legislation and the type of service provided, giving preference to those with encrypted video and audio-call features (secure streaming with TLS/SSL certificate) based on WEBRTC protocol in synchronous model and with end-to-end asynchronous text conversation with encrypted and secure transport (TLS/SSL certificate) with information stored only on end devices in encrypted database (smartphones, computers or tablets). The area restricted to collaborators contained stages of completion: 1^st, informed consent about the research; 2^nd, pre-service questionnaire with information on the use of technologies in life; 3^rd, on-line psychological services provision contract; 4^th, link to test the connection speed before the sessions, in order to indicate the quality of the connection at the moment before the session; 5^th, area for attaching session materials such as scanned copies and personal documents. The website contained access to install the chat application, whose specifications contained video and audio calls encrypted in synchronous mode (video calls) and with end-to-end asynchronous messaging capability, with encryption and storage of information only on devices and one-day message deleting feature.

(f) ethical issues for online intervention

In online mental health interventional research, ethical conditions must be considered not only in the context of the research, but also of the intervention and, in particular, of technological aspects. The experimental character of such mediation in the treatment should be highlighted, in order to guide the collaborators to the best choice for treatment.

The Informed Consent for participation in the research was prepared, as well as a contract for the provision of psychological services, in which aspects beyond those envisaged in a psychotherapeutic contract were addressed, adding information regarding the online information. Unlike in-office consultations, in the online environment both parties must be informed and co-responsible for minimum security, confidentiality and privacy care, such as choosing a private location without interference from third parties, storing data, being aware of the impossibility of sharing the information exchanged during treatment, the impossibility of recording and disseminating the contents, the limitations of the Internet (such as, for example, traffic and receiving and response time for messages), it is suggested to inform a professional address (in the case of the psychologist) and contacts of health services and people nearby for emergencies, procedures in case of connection failure, use of private internet and compatible devices for video calls.

Discussion

A first aspect of discussion refers to the knowledge of specificities of the participants in an online study with a restricted audience, which meant an important route to the design of the project. In this aspect, the delimitation of the theoretical foundation used to understand the findings, phenomenology, which is intended to be a description of experiences intentionally lived by the researcher, and the careful recording of contact with collaborators, recorded in a field diary, reinforced and highlighted some elements that the national literature has pointed out as points of attention (Prado & Meyer, 2006; Bordini & Sperb, 2011; Pieta & Gomes, 2014; Siegmund & Lisboa, 2015). The narratives about the mediation of technologies in psychological care with people in the area point out that most psychologists who provide care in a digital environment do not problematize the theme. As noted in the researcher’s field diary and according to Siegmund and Lisboa (2015), online psychological counseling in the perception of psychologists is seen as a secondary practice to on-site care. According to the study cited, professionals reported impersonality, lack of body interaction and difficulty expressing emotions as difficulties. Some were opposed to the online practice, albeit without justification (Siegmund & Lisboa, 2015; Levisky & Silva, 2010). A reduced and negative view of the use of technologies in online therapies is confirmed, however, it is noticed that in a naturalized way, contact is made available via asynchronous messages through conversation applications with the people served, outside the session time, without paying attention to the security, secrecy and digital privacy aspects of the contents treated in a psychotherapy process and conveyed by asynchronous messages. Such naturalization of the use of social networks as a form of contact outside the office, without proper evaluation of the terms of use of the applications, suggests a lack of information and knowledge about the details of synchronous and asynchronous therapies and the resulting online risks. The indiscriminating use of technologies and the condition of secondary intervention contextualizes a practice that lacks concerns about digital security, which can sometimes expose the person served to third parties, meaning an important ethical failure regarding confidentiality.

Challenges that psychologists face in relation to digital media in life and in the economy is also a problem for the category, as cultural changes have an impact on the supply of services, with an increase in demand from people seeking online services, in addition to the facilitated insertion of newly graduated professionals in digital platforms in search of placement in the market, with little clinical experience and theoretical and technological foundations. Such concerns have already been pointed out, such as a Brazilian interventional study, carried out with an online focus group, which suggests that the participants’ familiarity with the environment is a differential of the intervention’s success (Bordini & Sperb, 2011). Psychological theories, on the other hand, endorse the topic as a taboo, especially because in most reports, bodily presence is essential, and the analysis of gestures and behaviors, control of the environment, are fundamental tools in the therapeutic relationship. According to Cantone et al. (2021) and the notes of the research field diary, psychologists who follow psychodynamic approaches, especially, were more restrictive to the practice, considering it only in a complementary context, giving relevance to geographical displacement, to the waiting room, the physical environment and body contact, as important factors in the process. Online therapies would be justified in cases of geographical changes of people who were already in treatment. Nevertheless, the use of the Internet does not show significant differences regarding the practice of online and face-to-face psychoanalytic psychotherapy, with appropriate therapeutic alliances in both (Sfoggia et al., 2014; Pieta & Gomes, 2014; Prado & Meyer, 2006), which suggests an important gap between academic findings and practices, even within psychology training institutions, and that studies on different approaches to the mediation of technologies in psychotherapy are essential to confirm or refute such conceptions.

Considerar as diferentes abordagens clínico-teóricas pode trazer resultados profícuos e, ainda, verificar se a baixa produção acadêmica, em especial no Brasil, é decorrente de crenças pessoais sobre o on-line dentro dos ambientes de pesquisa. Enfatiza-se que, como consequência da escassez de estudos dentro do contexto brasileiro, tem-se o aumento de uma prática acrítica, permeada por concepções sem reflexões, sem normativas que fundamentem essa modalidade de atendimento.

Studies aimed at the subjective perception of technological influences is a relevant topic for Psychology as a science and profession. Considering the different clinical-theoretical approaches can bring fruitful results and, also, verify if the low academic production, especially in Brazil, is due to personal beliefs about the online mode in research environments. It is emphasized that, as a consequence of the scarcity of studies within the Brazilian context, there is an increase in an uncritical practice, permeated by conceptions without reflections, without regulations that support this type of care. As a result of personal/professional beliefs without scientific support, there is a regulation of a practice lacking guidelines, influenced and manipulated by advertising, immediacy and consumerism, with little ethical support, unlike what is seen in countries like the USA (APA, 2013), Spain (Consejo Generale dela Psicología em Spaña, 2017), among others, which regulated, in a systematic and informed way, such interventions. In addition, the lack of knowledge of basic technology concepts favors non-protective practices with regard to information security, disinformation about the referenced legislation and data protection, such as end-to-end encryption, secure applications and private environments, which results in urgent training of professional psychologists to enter the digital world in order to respect and comply with legislation for the conscious and ethical use of tools at the undergraduate or continuing education level.

The use of technologies provides an opportunity for mental health professionals to expand their practical capabilities, with psychologists and providers being responsible for the quality of these services (Luxton, Pruitt, & Osenbach, 2014). Security also in the elaboration of a service provision contract that specifies the conditions of service, in order to protect and guide both the person seeking the service and the professional who provides the service online, in which both must agree and be co-responsible for the limitations of the Internet, which is a new aspect for clinical practice. Moreover, it is important to promote discussions in the academic environment on professional conduct and posture and digital imaging, clinical management of treatments via the web, security settings and theoretical reflections on the effectiveness of different approaches in the online environment.

Intervention studies mediated by the Internet must start from an interdisciplinary survey in order to recognize the field. The effects of the Internet act on subjectivities, being relevant the training of the psychological look for the influences of technologies, their specificities and characteristics, their ways of being and being in relation to people. The online universe is more than a technological resource, it means modes of existence in a non-physical environment, where aspects of offline life are simultaneously configured, in a dimension that deserves deepening and psychological care. As an example, it is important to study how cyber culture establishes new social skills (Ferreira & Deslandes, 2018), such as affective x online relationships (Dela Coleta, Dela Coleta, & Guimarães, 2008), information x online information, dependence x technological dependence, violent communications (Silva, 2020; Pereira, 2017) such as self-mutilation among young people vs. online self-mutilation, bullying vs. cyberbullying, suicidal ideation vs. bullycide, as well as influences on different age groups and development. It also points out the trends in the use of artificial intelligence in mental health actions, of virtual reality in psychiatric treatments (Riva, 2022).

The interdisciplinary study with philosophy, anthropology, sociology, communication and information technologies, law, medicine, arts, among others, is the gateway to an attentive and capable psychological science to treat the sufferings that derive from this context still little explored, in which consolidated theories are not enough to explain the effects that have repercussions on humans.

Psychology services mediated by the Internet, including research and practices in online psychotherapy, must encompass the necessary knowledge of communication and information tools and technologies, which meet the criteria of privacy and security of materials posted on the Internet and that dialogue as Code of Ethics for Psychologists. According to the CFP Resolution of May 2018, which regulates the provision of psychological services performed through information and communication technologies, cites in article IV, § 2 that “[…] in any modalities of these services, the psychologist will be obliged to specify the technological resources used to ensure the confidentiality of information and to clarify the client about it” (CFP, 2018a, p. 1). It is essential that the professional has knowledge of technologies and, still, keeps themselves in continuous improvement, since it is a dynamic area, whose specifications are updated in a short space of time, in search of a constant adaptation of equipment, reflections and choices of technologies that meet the needs of the service or study that is intended to be offered. As for research based on Internet interventions, specifically for online psychological care, studies on the different types of applications and platforms of service are recommended, considering technical and qualitative aspects as criteria for choosing technologies:

In the technical aspects, it is suggested: (1) applications that use encryption technology, (2) which have end-to-end communication, (3) preferably with open source, certified by a specialist in the IT area, (4) use of the private non-public internet and (5) use of original systems with native antivirus.

As for the qualitative aspects, it is recommended: (1) a detailed evaluation of the resources and their privacy policies, in order to adapt to the intervention proposal. In the case of online psychotherapy, it is suggested (2) careful evaluation in the choice of modality, whether synchronous or asynchronous or mixed, with due differentiation of benefits and limitations of each one and the consequences on the therapeutic relationship, as for example, in the case of insertion of technologies with text or audio message functions, which promote interactions other than the video call, (3) that serve different devices, cell phone, notebook, iPad, personal computer, tablet and capable of configuring multiple authentication factors, such as biometrics, password, deletion of message in a preset time (4) evaluation of the relevance and mastery of the tools used by the professional, paying attention to the repercussions of online mediation for each person, (5) evaluation of familiarity and digital literacy of the person who will be assisted, as well as a (6) detailed assessment for the reason for choosing this type of intervention, (7) information, awareness and science of all interlocutors about possible limitations and security risks inherent in the online environment.

In addition to these, some care is required to maintain the quality of online services: (1) other forms of contact must be combined in the event of an abrupt disconnection from the session, in order to alleviate discomfort. As an example, mobile phone with encrypted text messaging application for contact or mobile data network usage, offering dual connection network in case of electrical or private network failure. (2) contacts of people and territorial mental health resources, in case of emergencies, confirmation and proof of data (CFP, 2018a, Conselho Federal de Psicologia [CFP], 2018b); (3) it is suggested that the professional also informs the physical and professional address contacts.

As a reflection of digital media in life, in addition to being careful about their influences on psychology, it is important to consider that scientific research begins to impose new needs on researchers, which makes it relevant for research centers to invest in the development of safe virtual environments, encourage interdisciplinarity, in order to guarantee ethical respect for volunteers. Thus, it is essential that research involving new technologies pay strict attention not only to the foundations, methods and results, but, above all, to the specific criteria of the technologies, such as ethical and legal aspects of information security, storage and handling. data online.

Final considerations

In a phenomenological understanding, life is lived and cohabited with other people without problematizing objects, considered familiar, often considering them as true, when, in reality, they present only one of the possibilities that is revealed in a polyhedral perspective (Trilles- Calvo, 2019).

From a phenomenological perspective, in order to understand psychotherapy mediated by technologies, it is essential to take a previous step and ask the question of what online is specifically. The insertion of technologies in everyday life has increasingly taken place as part of life, in an indissoluble and uncritical way, inserting itself in the context of psychological practices, often without reflections or designs that accompany their repercussions for the treatment and care of people. psychologically vulnerable, which implies the need to turn to digital technologies properly, in an attempt to understand what they have been driving in society and culture and how to understand this phenomenon in the world of life. Prior to understanding its effects on psychotherapy, it is a matter of questioning the phenomenon in its cultural, social and anthropological aspects, in order to locate the transformations that this virtuality promotes in subjectivity and intersubjectivity (Silva & Morujão, 2021).

The fluidity of the online phenomenon requires special attention not only to the effects on subjectivity and everyday life, but also on the practices of psychology and the design of research involving interventions on the web, prior to the technical-psychological background. According to Proudfoot et al. (2011), theories supporting online therapies are derived from face-to-face interventions and, in this sense, there is a lack of systematization resulting from online experiences and treatments, in order to guarantee, at least, reflections on the ethical care of people in psychic vulnerability who seek this type of intervention.

This article aimed to raise aspects about the structuring of studies on intervention mediated by the internet, resulting from the elaboration of the design of a longitudinal qualitative study of online psychotherapy at the postdoctoral level. In this way, it is not intended to present research results, but rather to promote a careful look at relevant aspects for research and interventions occurring in the web environment and their specificities, in dialogue with the international literature.

The influences of new technologies are increasingly present, not only in aspects of work, leisure, culture, relationships, but also in the consumption and offer of products and services. Thus, it is urgent for Psychology to consolidate a field of knowledge that seeks to understand the influences of technologies on the way of living and on subjectivities, their social, cultural and economic implications and, also, to outline with scientific rigor the possibilities and limitations of the use of internet for mental health care. It is a vast field of research, with ample need for studies, population, methodologies, types of intervention and scope, a field that will require many rigorous investigations.

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• 1
  Support and funding: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), proc. 2018/11351-2 and 2019/20357-7.

Publication Dates

• Publication in this collection
  31 Mar 2023
• Date of issue
  2023

History

• Received
  13 July 2020
• Accepted
  21 Nov 2021