Online psychotherapy

helpkeyTelepsychiatry 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.


6 comments to Online psychotherapy

  • Thank you for detailing some of the issues involved with telepsychiatry, especially when it comes to doing therapy. I just read an article that made me cringe at how little the therapist profiled in the article seemed to worry about the implications of mostly-online interactions.

    I do wonder about whether in the near future people will come to expect the convenience and instant gratification of having a therapist available via computer or smartphone. Or will humans always prefer live social interactions? Or will the norm be some kind of hybrid mix of the two?

    • Hi, thanks for visiting. The therapist in that Atlantic article sounds intentionally provocative. He flouts privacy concerns and frame issues with gusto, and grooms his online persona to signal that he’s not worried about the implications of anything. I’m not surprised he’s popular, as many people are drawn to iconoclasts and anti-heros.

      I can’t predict even the near future of online therapy. If I had to guess, I’d say more therapists will offer it (since it’s easy to set up), and a growing subset of patients will prefer it. Most, though, will continue to want a more visceral therapy encounter, especially after having spent the rest of their day in front of glowing screens. If you have your own thoughts on this, post away.

  • TK

    In today’s mobile society, telepsychiatry makes it possible for long-standing therapeutic relationships to continue when a person relocates due to job, economics, caring for an ill relative, or whatever. Far better, in my opinion, to continue by Skye than to end the relationship artificially just because the two people can’t physically be in the same room. At the very least, it should be tried. If the client says that it is working for them effectively, then it’s working. Far better than a patient feeling abandoned because therapist won’t adapt to the new technology, or having to search for an excellent new therapist some place else and begin all over again.

    • Although I agree with your general point, I say it all depends. Recently a longstanding patient asked for Skype psychotherapy as her new, distant job made it hard to attend regularly in person. I agreed to give it a try. In our first and only Skype session, my patient was locked in her vehicle with her cellphone, as she had no privacy either at work or at home. The video signal was poor, and it lagged behind the audio. It was hard to tell a pause in conversation from a technical delay. She and I agreed that going forward it would be better simply to come in person less often.

      I assume Skype usually works better than this. Even so, my experience illustrates some of the trade-offs. Does the patient have a private place to talk? Do limitations in the medium add uncertainty about what is happening interpersonally? Can both parties “get into” the material and not be distracted by the technology? And most important, what are the alternatives? If there are no good alternatives, then sure, even a bad Skype call is better than nothing. And a good Skype call with a good and/or familiar therapist is likely preferable to seeing a mediocre therapist in person.

      However, when it comes to “ending a relationship artificially” or making a patient “feel abandoned,” I’m not as quick to jump on board. A relationship that starts as in-person treatment doesn’t end “artificially” if one party fails to switch to talking to a screen. Consider the converse: What if I told all my patients I’d now see them only using FaceTime, not in person, and suppose half of them refused. Would they be ending the relationship artificially? Not in my book. And if I had a patient who left town and then felt abandoned when I refused to conduct therapy long-distance, I’d point out that he or she has abandon-er and abandon-ee mixed up.

      Don’t get me wrong. I’m sure in many instances online psychotherapy works better, for both parties, than the available alternatives. I certainly don’t think it always does, and frankly I don’t automatically assume patients are right when they tell me some aspect of psychotherapy is “working for them effectively.” As mentioned in the post, some patients would choose not to leave their houses when it would be therapeutic to do so, and part of my job is to advise patients on what I believe is in their best interest, not what they want to hear. Thanks for writing.

  • Anon

    I think a lot is lost when therapy is not done in person. I moved to another city, and my therapist and I agreed to continue therapy by phone. I find myself doing other things while I’m talking to my therapist just as I do when I’m chatting with my sister or a friend on the phone, and sometimes I hear papers rustling on her end of the line. I don’t think on either side full attention is paid when it’s by phone, not purposefully, it’s just how it works out. I can avoid facing things a lot easier when I’m not sitting right in front of her. I suspect I’m not alone in that.

  • Thank you for this post, I find it very relevant for my recent research.
    I just wanted to comment that today there is a variety of online HIPPA complaint video conferences software.
    For my practice, I am using and as for the EMR software I am using

    Thank you!

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